Final Review Flashcards
(511 cards)
1
Q
Pregnancy is a normal physiologic state, and physiological parameters in pregnancy are altered—T/F
A
True
2
Q
MAC is ___ (increased/decreased) in pregnancy
A
Decreased
3
Q
Pregnancy causes ___ (increased/decreased) sensitivity to local anesthetics
A
Increased
4
Q
Ventilation in pregnancy is ___ (increased/decreased)
A
Increased
5
Q
Tidal volume is increased ___% at term
A
40%
6
Q
Respiratory rate ___ (increases/decreases) during pregnancy
A
Increases—15%
7
Q
Minute ventilation is ___ (increased/decreased) during pregnancy
A
Increased—50%
8
Q
PaCO2 ___ (increases/decreases) during pregnancy to ___-___ mm Hg
A
Decreases to 28-32 mm Hg
9
Q
PaCO2 decreases during pregnancy d/t ___ventilation, respiratory ___osis,
A
Hyperventilation, respiratory alkalosis
10
Q
Body compensates to respiratory alkalosis during pregnancy by excreting ___ ions to maintain a normal pH…this leads to ___ (what acid-base balance?)
A
Bicarbonate ions; leads to metabolic acidosis
11
Q
Expanding uterus pushes the diaphragm ___
A
Cephalad (up towards head)
12
Q
FRC decreases by ___% in pregnancy
A
20%
13
Q
There are no changes in vital capacity or total lung capacity during pregnancy—T/F?
A
True
14
Q
FRC ___ (increases/decreases) during pregnancy
A
Decreases
15
Q
Maternal oxygen consumption ___ (increases/decreases) during pregnancy
A
Increases
16
Q
Decrease in FRC and increase in maternal O2 consumption makes it more likely for mom to develop maternal ___ during induction of general anesthesia
A
Maternal hypoxia
17
Q
Need to ___ prior to induction because there is such a high risk of maternal hypoxia
A
Pre-oxygenate/denitrogenate
18
Q
P50 of hemoglobin ___ (increases/decreases) from ___ to ___ mm Hg
A
Increases from 27 to 30 mm Hg
19
Q
Increase in P50 of hemoglobin during pregnancy allows for ___
A
Oxygen delivery to the fetus
20
Q
Dead space in pregnancy is ___ (increased/decreased)
A
Decreased
21
Q
Airway resistance in pregnancy is ___ (increased/decreased)
A
Decreased
22
Q
Congestion of respiratory mucosa occurs during pregnancy secondary to vasodilation—T/F?
A
True
23
Q
Lots of soft tissue in the neck, chest, and breasts may cause obstruction and difficulty placing laryngoscope properly; a shorter laryngoscope handle should be available for use—T/F?
A
True
24
Q
Mucosal venous engorgement/edema creates risk for bleeding in airway with intubation—T/F?
A
True
25
Nasal instrumentation should be avoided in pregnant patients—T/F?
True
26
Larger ETTs should be used for pregnant women—T/F?
False...want to use SMALLER ETT—6.5, 7.0, or 7.5 ETT
27
What induction technique should be used to prevent maternal hypoxia?
Rapid sequence induction with cricoid pressure
28
Goal is to maintain ___carbia during general anesthesia
Normocarbia
29
Avoid ___ventilation because decreased PaCO2 will cause uterine vaso___; ___ (increased/decreased) placental blood flow; and metabolic ___ in the mother
Avoid hyperventilation; cause uterine vasoconstriction; decreased placental blood flow; metabolic alkalosis in the mother
30
Metabolic alkalosis in the mother will shift the oxyhemoglobin curve to the ___, so maternal hemoglobin will ___
To the left, so maternal hemoglobin will hold onto oxygen and not release it to the fetus
31
Plasma volume ___ (increases/decreases) during pregnancy by ___%
Increases by 45%
32
RBC volume ___ (increases/decreases) by ___%
Increases by 20%
33
Sodium/water retention occurs in pregnant patients—T/F?
True
34
Pregnant patients are hypervolemic—T/F?
True
35
Cardiac output ___ (increases/decreases) in pregnancy by ___%
Increases by 40%
36
HR ___ (increases/decreases) by ___%
Increases by 15-30%
37
Stroke volume ___ (increases/decreases) by ___%
Increases by 30%
38
In pregnancy, the oxyhemoglobin dissociation curve shifts to the ___
Right—so maternal hemoglobin releases O2 to be delivered to the fetus
39
Peripheral vascular resistance ___ (increases/decreases) in pregnancy by ___%
Decreases by 15%
40
Why does PVR drop in pregnancy?
Increased progesterone relaxes venous smooth muscle
41
Cardiac output change in latent (inactive) phase of labor = ___% increase
15% increase
42
Cardiac output change in active phase of labor = ___% increase
30% increase
43
Cardiac output change in second stage of labor = ___% increase
45% increase
44
Cardiac output change postpartum = ___% increase
80% increase
45
Pregnant women’s response to adrenergic drugs is increased—T/F?
False—response to adrenergic drugs is blunted in pregnancy
46
CXR will show cardiac hypertrophy during pregnancy—T/F?
True
47
Heart murmurs auscultated during pregnancy are a cause of concern—T/F?
False—heart murmurs are common on auscultation in pregnant women
48
Systolic murmurs are ___
Normal
49
Diastolic murmurs are ___ if heard
Pathologic
50
S3 heart sound may be heard during pregnancy—T/F?
True
51
There is a ___ (increase/decrease) in plasma colloid osmotic pressure d/t relative hypervolemia that occurs during pregnancy
Decrease
52
Supine hypotension syndrome is aka ___
Aortocaval compression
53
Aortocaval compression syndrome occurs in ___% of term parturients when they lie flat
20%
54
Symptoms of aortocaval compression = ___tension, ___, ___, ___, ___
Hypotension, pallor, nausea, vomiting, diaphoresis
55
Can see symptoms of aortocaval compression as early as ___ weeks gestation
20 weeks
56
Treatment for aortocaval compression = place patient in ___ position
Left lateral uterine tilt position
57
Cell mediated immunity is ___ (increased/decreased) during pregnancy
Decreased
58
Pregnancy creates a hypercoaguable state, putting parturients at higher risk for PE—T/F?
True
59
Fibrinogen is ___ (increased/decreased) during pregnancy
Increased
60
PT and PTT ___ (increased/decrease) by ___%
Decrease by 20%
61
Renal blood flow/glomerular filtration are both ___ (increased/decreased) by 50% by the 16th week of pregnancy; remains ___ until delivery
Increased; remains elevated
62
Serum BUN and creatinine are mildly ___
Reduced—may see BUN 8, creatinine 0.5
63
Mild glycosuria/proteinuria is common in pregnancy—T/F?
True
64
Increased progesterone ___ (increases/decreases) gastroesophageal sphincter tone; displacement of the stomach by the uterus also ___ competence of the gastroesophageal sphincter
Decreases; reduces
65
___ (increased/decreased) risk of symptomatic aspiration during pregnancy
Increased
66
There is a 20% decrease in pseudocholinesterase levels in pregnancy, so the amt of succs administered should be reduced—T/F?
True
67
Gallbladder becomes sluggish during pregnancy, can result in gallstones—T/F?
True
68
Albumin levels are increased in pregnancy—T/F?
False—decreased albumin levels, affects protein-bound drugs
69
Insulin resistance occurs during pregnancy d/t higher plasma glucose levels in the parturient—T/F?
True
70
Oxygen transfer between mom and baby depends on mom’s ___ blood flow and fetal ___ blood flow
Mom’s uterine blood flow and fetal umbilical blood flow
71
O2 has the smallest storage to utilization ratio in the fetus—fetus can store ___ ml of O2 and O2 consumption is ___ ml/min
Store 42 ml of O2 and O2 consumption is 21 ml/min
72
Placental blood PaO2 = ___ mm Hg
40 mm Hg
73
Mom has a ___ (left/right) shift in oxyhemoglobin curve
Right shift—releases O2 to fetus
74
Fetus has a ___ (left/right) shift in oxyhemoglobin curve
Left shift—accepts O2 from mom
75
Fetal hemoglobin is ___ (lower/higher) than maternal hemoglobin
Higher
76
Fetal hemoglobin has a ___ (lower/higher) affinity for CO2 than does maternal hemoglobin
Lower
77
Uterine blood flow is ___% of cardiac output— ___ ccs per min
10%—700 ccs per min
78
Under normal conditions, uterine blood flow is only ___ ccs per min
50 ccs per min
79
___% of uterine blood flow goes to the placenta; the rest goes to the myometrium (uterine muscle)
80%
80
What are (3) factors that influence uterine blood flow?—systemic ___, uterine ___, uterine ___
- Systemic BP
- Uterine vasoconstriction
- Uterine contractions
81
Propofol and thiopental mildly reduce UBF via maternal hypotension—T/F?
True
82
Induction agent dosages can be cut by 1/3-1/2 of the usual doses to minimize maternal hypotension—T/F?
True
83
Volatile agents ___ (increase/decrease) UBF secondary to hypotension
Decrease UBF
84
At < 1 MAC, hypotensive effects of volatile agents are minor—T/F?
True
85
Can keep volatile agents ___ MAC because pregnancy ___ (increases/decreases) MAC
< 1 MAC because pregnancy decreases MAC
86
Ketamine, nitrous oxide, and opioids have ___ effect on UBF
Little to no effect
87
High serum local anesthetic levels can result in uterine vaso___
Vasoconstriction
88
Goal is to maintain ___tension in pregnant mom so baby continues to get adequate blood flow via placenta
Normotension
89
Neuraxial analgesia ___ (increases/decreases) maternal catecholamine levels and reduces vasoconstriction, thus improving uterine blood flow
Decreases
90
Once baby is born, pulmonary vascular resistance [in the baby] ___ (increases/decreases) as oxygen enters the lungs
Decreases
91
If baby isn’t crying when born and still isn’t crying after stimulation, you need to initiate ___
Positive pressure ventilation
92
Hypoxia or acidosis will increase ___ shunting through the ductus in the newborn, creating a ___
Increase R to L shunting; creates a “downward spiral”
93
Downward spiral = ___ of the newborn
Persistent pulmonary hypertension of the newborn (occurs when baby is hypoxic/acidotic, blood backs up into R side of heart, causing pulmonary hypertension)
94
Stages of labor:
Stages 1, 2, and 3
95
Stage 1 of labor is divided into two phases—___ phase and ___ phase
Latent phase and active phase
96
Latent phase of labor = minor dilation of cervix ___-___ cm, ___ (frequent/infrequent) contractions
Minor dilation of cervix 2-4 cm, infrequent contractions
97
Active phase of labor = progressive dilation to ___ cm and ___ (regular/irregular) contractions every ___ to ___ minutes
Progressive dilation to 10 cm and regular contractions every 3 to 5 minutes
98
Stage 2 of labor = time from ___ until ___
Complete dilation until infant delivered
99
Stage 3 of labor = time from ___ until ___
Delivery of infant until placenta delivered
100
Ptocin (oxytocin) can ___ (increase/decrease) rate of contractions to every ___ to ___ minutes
Increase rate of contractions to every 1-1.5 mins
101
Uterine atony = uterus does ___ contract; risk for ___
Does not contract; risk for massive bleeding
102
Uterine atony can be caused by too much ___
Oxytocin (ptocin)
103
What is the most common complication of neuraxial blocks?
Nerve injury
104
Insertion and removal of epidural catheter should only occur when ___ is normal
Coagulation function
105
Always make sure that the tip of the catheter is ___ upon removal
Intact
106
In pregnant women with no history of bleeding problems, no signs/symptoms of PIH, not on anticoagulation, it is safe to proceed with neuraxial block—T/F?
True
107
Patients with PIH and neuraxial blocks—platelet count > ___ is required before proceeding with block; normal ___, ___ are also required
> 100k; normal PT, PTT are also required
108
If patient is on low molecular weight heparin, consider ___ instead of neuraxial block
IV analgesia
109
Avoid block for ___ hours if therapeutic on anticoagulation
24 hours
110
Avoid block for ___ hours if prophylactic anticoagulation
12 hours
111
Remove catheter at least ___ hours after last dose
At least 12 hours
112
Do not administer LMWH until ___-___ hours after block is placed or catheter is removed
2-4 hours
113
Avoid concurrent ___ or ___ with neuraxial blocks
NSAIDs or anticoagulants with neuraxial blocks
114
What are two main signs of epidural hematoma?—bilateral ___ weakness and ___ pain
- Bilateral leg weakness
| - Back pain
115
What are two other signs of epidural hematoma? (think bowel/bladder)
- Incontinence
| - Absent rectal sphincter tone
116
If epidural hematoma is suspected, patient must get a stat ___
CT/MRI
117
Surgical decompression of epidural hematoma must occur within ___ hours for full neurological recovery to occur
6 hours
118
If an epidural abscess is present, can take ___-___ days for signs to occur
4-10 days
119
Treatment of epidural abscess = ___ and ___
Antibiotics and laminectomy
120
Treatment of epidural abscess—have ___-___ hour window before permanent damage ensues
6-12 hour
121
Epidural abscess s&s—severe ___ pain that is worse with ___
Severe back pain that is worse with flexion
122
Epidural abscess s&s—exquisite ___ tenderness
Local
123
Epidural abscess s&s—___, ___, meningitis-like ___ with ___ stiffness
Fever, malaise, meningitis-like headache with neck stiffness
124
Lab changes with epidural abscess—___ WBC, ___ ESR, ___ blood culture
Increased WBC, increased ESR, positive blood culture
125
Transient neurological symptoms (TNS) = pain and dysthesia in ___, ___, or ___ that can follow a subarachnoid block, resolves within ___ hours
Pain and dysthesia in buttocks, legs, or calves that can follow a SAB, resolves within 72 hours
126
Dysthesia = abnormal ___
Sensation—can be aching, burning, prickling feeling
127
TNS is most commonly caused by ___ spinals
Lidocaine—more common with high doses of concentrated lidocaine 5%
128
Compression injuries are very common d/t ___ position
Lithotomy
129
Post-dural puncture headache = ___ headache
Spinal headache
130
Spinal headache is throbbing, postural***, with variable distribution—T/F?
True
131
Onset of spinal headache is typically ___-___ hours after dura puncture
12-48 hours
132
Duration of spinal headache
Few days to weeks
133
___ gauge and ___ needles increase PDPH incidence
Larger gauge and cutting edge needles
134
___ point needles are significantly better than ___ tip needles because dura fibers are not cut but just pushed apart
Pencil point needles are better than cutting tip needles
135
Hallmark sign of PDPH =
Continuous headache when in upright position (i.e.: sitting or standing)
136
Relief from PDPH only comes when ___
Laying completely flat
137
Non-invasive treatment of PDPH =
Bed rest
138
Most PDPH resolve within ___ week
1
139
Other non-invasive treatment modalities for PDPH include PO, IV, epidural analgesics—i.e.: NSAIDs, acetaminophen, opioids; cerebral vasoconstrictors—i.e.: PO/IV caffeine, theophylline, sumatriptan—T/F
True
140
Definitive treatment of PDPH = ___
Epidural blood patch
141
What is this describing?—epidural space is identified and 15-20 ccs of patient’s own blood is injected into the epidural space; clotting factors in the blood help seal the hole in the dura; try to inject at the same level as the initial dural puncture
Epidural blood patch
142
Epidural blood patch—start slow and stop either when patient says headache is gone or they have a pressure sensation in the ears—T/F?
True
143
What is the most common cause of perioperative headache?
Caffeine withdrawal
144
Total spinal anesthesia = ___tension, ___nea, ___nia
Hypotension, dyspnea, aphonia
145
Management of total spinal—place patient in ___ position
Left uterine displacement/trendelenburg position
146
Treatment of total spinal—early resuscitation, ventilation, and circulatory support are essential; epi may be needed; intensive maternal/fetal monitoring are crucial—T/F?
True
147
Management of total spinal—can give naloxone for intraspinal opioid—T/F?
True
148
Urgent C-section is mandatory for treatment of total spinal—T/F?
False—NOT mandatory—decision is based on fetal assessment after maternal stabilization
149
OB population is at increased risk for ___
Aspiration
150
Aspiration is high risk in parturients because they have more ___ which causes smooth muscle ___; gastric sphincter is ___
Progrestrone; smooth muscle relaxation; gastric sphincter is relaxed
151
Moms have ___ (slower/faster) gastric emptying
Slower
152
Moms have ___ (higher/lower) gastric pH
Lower
153
Suspect ___ with hypoxia, pulmonary edema, bronchospasm
Aspiration
154
Aspiration prevention in parturients = ___ pressure
Cricoid pressure (Sellick’s maneuver)
155
Aspiration prevention—elective C-section patients should fast for at least ___ hours, even if regional is planned
6 hours
156
Always assume a ___ stomach in parturients
Full
157
Sodium citrate can be given to ___ gastric pH; works within ___; lasts ~___ mins
Raise gastric pH; works within minutes; lasts ~30 mins
158
H2 blockers take at least ___ minutes to work
30 minutes
159
Reglan facilitates ___, requires ___-___ minutes
Gastric emptying, requires 40-60 mins
160
Pain pathways—1st stage of labor—pain source is primarily ___
Lower uterine segment from contractions (T10-L1)
161
Pain pathways—2nd stage of labor—pain source is ___ structures via ___ nerve
Perineal structures via pudendal nerve (S2-S4)
162
All opioids cross the placenta and depress the fetus—T/F?
True
163
___ provides great satisfaction scores, less neonatal depression, less nausea, less risk of maternal respiratory depression
PCA
164
This medication causes increased risk of respiratory depression for neonate d/t immature BBB and is not often used
Morphine
165
This medication onset is 5 minutes; has a very long half-life of 18-23 hours; respiratory depression can be avoided if this medication is given less than 1 hour before delivery; has active metabolites; causes frequent nausea, vomiting; do NOT give to patients with seizure history or renal failure
Meperidine (Demerol)
166
This medication is 100x more potent than morphine; onset is 3-5 minutes; rapid transfer across the placenta; respiratory depression may outlast analgesia; you can give a loading dose of this medication through PCA
Fentanyl
167
This medication is a mu opioid antagonist, kappa agonist; there is a ceiling effect on respiratory depression from this medication but there is no difference in side effects; great for helping mom get through the worst of her contractions; only lasts 45 mins-1 hour
Nalbuphine (Nubain)
168
Nalbuphine (Nubain)—___ is common with this medication
Dysphoria
169
Nalbuphine (Nubain) can be used to treat ___
Opioid pruritis
170
Some reports suggest that this medication offers better analgesia than fentanyl; sedation is common; there is a ceiling effect on respiratory depression
Butorphanol (Stadol)
171
Meperidine (demerol) has a very long half life of ___-___ hours
18-23 hours
172
Meperidine (demerol)—respiratory depression can be avoided if this medication is given ___ hour before delivery
1
173
Meperidine (demerol) has ___
Active metabolites
174
Meperidine (demerol) should NOT be given to patients with ___ history or ___ failure
Seizure history or renal failure
175
___ block can be used during the 1st stage of labor; risks include accidental injection into uterine artery, fetal local anesthetic toxicity, nerve injury, or hematoma
Paracervical block
176
___ block can be used during the 2nd stage of labor; good for patients with contraindications to neuraxial block; needle is placed transvaginally under ischial spines; risks include injury, infection, hematoma
Pudendal block
177
Local anesthetics—amino ___ are derivatives of PABA (known allergen); metabolized by plasma cholinesterase; examples include cocaine, procaine, chlorpromazine, tetracaine
Esters
178
Local anesthetics—amino ___ are metabolized by the liver; no PABA; true allergies are rare; examples include lidocaine, bupivacaine, prilocaine, ropivacaine, etidocaine
Amides
179
Local anesthetics—lipid solubility = ___
Potency
180
Local anesthetics—the more lipid soluble, the more ___ diffusion
Placental
181
Local anesthetics—protein binding influences ___...increased protein binding = ___ (shorter/longer) duration
Duration of action...increased protein binding = longer duration
182
Local anesthetics—high protein binding ___ (increases/decreases) placental transfer
Decreases
183
Local anesthetics are weak ___
Bases
184
Local anesthetics work on the ___ channel
Sodium
185
PKA =
50% ionized, 50% nonionized
186
PKA determines the ___
Speed of onset
187
The closer the pKa to the physiologic pH, the ___ the onset
Faster
188
Can add ___ to artificially raise the pH and speed the onset of action
Sodium bicarbonate
189
Increasing dose of local anesthetic given = ___ onset, ___ duration
Faster onset, longer duration
190
Vasoconstrictors given with local anesthetics prevents ___ absorption
Vascular absorption
191
Increasing temperature of LA ___ onset time
Reduces
192
In pregnancy, should use ___ (more/less) local anesthetic; there will be a ___ onset of blockade, possibly due to progesterone
Less local anesthetic; there will be a faster onset of blockade
193
Bupivacaine, ropivacaine, and lidocaine should be used for ___ epidural anesthesia
Labor
194
Lidocaine and 2-chloroprocaine should be used for ___ epidural anesthesia
Operative
195
Tetracaine and bupivacaine should be used for ___ anesthesia
Spinal
196
This LA is used for labor epidural anesthesia; not used as a continuous infusion; can be useful as a top off and to test the function of an epidural catheter; used to activate epidural catheter for c-section; results in a lot of motor block; 45 min DOA
Lidocaine
197
This LA is used for epidural c/s; this is the only ester local used in epidural space; rapid onset, very short duration; results in lots of motor block; low risk of toxicity; very rapidly metabolized in the blood by pseudocholinesterase; do not use for spinals
2-chloroprocaine
198
2-chloroprocaine is contraindicated in patients with ___
Atypical pseudocholinesterase
199
This LA is used for epidural labor; long duration; less motor block than most other agents; produces refractory Vtach/VF if large IV dose is given accidentally
Bupivacaine
200
This LA is the L isomer of bupivacaine; less cardiotoxic; new drug; NOT approved for spinal
Levobupivacaine
201
This LA is less cardiotoxic than levobupivacaine; 25% less potent than bupivacaine; NOT approved for spinal
Ropivacaine
202
Epidurals should be dosed ___
Incrementally—every dose is a test dose!
203
___ is sometimes used as test dose for epidural
Epi
204
For OB epidural analgesia, it is best to cover ___-___ dermatomes
T10-S4
205
Spinal cord ends at ___ in most people
L1 (some people it ends lower at L2/L3)
206
Spinals should be placed below ___
L3
207
If at any time during epidural/spinal placement patient complains of paresthesia, you should ___
Remove the needle
208
___ line is the transverse line passing across the lumbar spine between the posterior iliac crests
Tuffier’s line
209
___ for epidural placement is becoming more common d/t obese population
Ultrasound
210
What is the #1 contraindication to neuraxial blockade?
Patient refusal
211
Other contraindications to neuraxial blockade—___ at the site of injection; ___pathy; intracranial ___; aortic ___; existing ___; hemodynamic ___
Infection; coagulopathy; intracranial mass lesion; aortic stenosis; existing spinal/neurological pathology; hemodynamic instability
212
Subarachnoid blocks for labor are more often used for ___
C-section
213
Combination of ___ is also used for labor
Spinal/epidural—spinal for the c/s and epidural for continued pain management
214
Combined spinal/epidural provides ___ relief; inject ___ dose first, then leave ___ catheter in place
Near instant relief; inject spinal dose, then leave epidural catheter in place
215
Problem with combined spinal/epidural is that it can make testing an epidural catheter difficult since pain impulses are already blocked from the spinal—T/F?
True
216
Sub dural block is done in the space between ___ and ___ mater
Dura and arachnoid mater
217
A sub dural block presents variably, from minimal effects to loss of consciousness/apnea—T/F?
True
218
Sub dural block may cause Horner’s syndrome—T/F
True
219
___ syndrome = dry mouth, miosis, ptosis, anhidrosis
Horner’s
220
A sub dural block should be replaced with an ___
Epidural
221
What is this describing?—uneventful placement of epidural; sensory change over 10-20 minutes; excessive spread of volume injected—high cephalad spread with poor caudal spread and sacral sparing; asymmetric distribution; minimal to moderate motor block; minimal or easily controlled hypotension
Sub dural block
222
Preterm labor = regular uterine contractions occurring at least every ___ minutes, resulting in cervical change prior to ___ weeks
10 minutes, prior to 37 weeks
223
Low birth weight (LBW) = any infant < ___ g at birth
< 2500 g (2.5 kg) at birth
224
Very low birth weight (VLBW) = any infant < ___ g at birth
< 1500 g (1.5 kg) at birth
225
Mortality approaches 90% for infants born < ___ weeks; survival exceeds 90% for infants > ___ weeks; survival is greater than 98% by ___ weeks
< 24 weeks; > 30 weeks; 34 weeks
226
Almost all infants at < 27 weeks gestation experience ___; by 36 weeks, they do not experience this
Respiratory distress syndrome
227
___ is proven safer in pre-term labor with breech presentation
C-section
228
Tocolytic therapy = attempt to ___ or ___ contractions and avoid ___
Slow down or stop contractions and avoid pre-term labor
229
Tocolytic therapy is used for ___-term, < ___ hours to permit corticosteroid treatment to aid fetal lung maturation or allow transfer to a better NICU facility
Short-term, < 48 hours
230
___ increases surfactant production in neonate’s lungs; takes about ___-___ hours for surfactant to build up; try to get 2 doses in before birth
Betamethasone; takes ~24-48 hours
231
Tocolytic therapy is used for gestational age ___-___ weeks, EFW < ___ g, absence of fetal ___
20-34 weeks, EFW < 2500 g, absence of fetal distress
232
Long-term tocolytic therapy is not proven to prolong gestation or reduce neonatal morbidity—T/F?
True
233
(5) types of tocolytic therapy:
- methylxanthines
- calcium channel blockers
- prostaglandins synthetase inhibitors
- magnesium
- beta adrenergic agonists
234
Tocolytic therapy—___ can become toxic very easily; frequent monitoring of peaks/troughs required; increases cAMP to produce uterine muscle relaxation
Methylxanthines (i.e.: aminophylline)
235
Tocolytic therapy—what therapy is this?—myometrium contractility is related to free Ca concentration; decreased Ca = decreased contractility
Calcium channel blockers (i.e.: nifedipine)
236
Maternal side effects of this drug class include hypotension, tachycardia, dizziness, palpitations, myocardial depression, conduction defects, hepatic dysfunction, hemorrhage, flushing, vasodilation, peripheral edema, decreased UBF leading to fetal hypoxemia and fetal acidosis
Calcium channel blockers
237
___ is a risk of calcium channel blocker therapy because the uterus can’t contract; uterine atony occurs that is refractory to ___ and ___
Postpartum hemorrhage; uterine atony occurs that is refractory to oxytocin and prostaglandin F-A2
238
What tocolytic drug class is this?—decreased cyclooxygenase causes decreased prostaglandin, causing uterine relaxation
Prostaglandin synthetase inhibitors
239
Indomethacin and sulindac are both ___
Prostaglandin synthetase inhibitors
240
Side effects of this medication class include nausea, heartburn, bleeding d/t low platelets, primary pulmonary HTN; moms feel horrible on this drug
Prostaglandin synthetase inhibitors
241
Fetal side effects of this drug class include premature closure of ductus, persistent fetal circulation, renal impairment, transient oliguria
Prostaglandin synthetase inhibitors
242
This drug competes with Ca for uterine smooth muscle surface binding, resulting in decreased contractility/smooth muscle relaxation; prevents increases in intracellular calcium; activates adenylyl cyclase, increases cAMP, causing uterine relaxation
Magnesium
243
___ is the drug of choice for tocolytic therapy/PTL
Magnesium
244
Magnesium makes patient more sensitive to ___
NMBs—decrease dosage used
245
Normal magnesium treatment range is ___-___mg/100mL
4-7 mg/100 mL
246
Magnesium 8-10 = loss of ___
Deep tendon reflexes
247
Magnesium 10-15 = ___ depression, wide ___, prolonged ___
Respiratory depression, wide QRS, prolonged PR interval
248
Treatment of magnesium toxicity = ___
Calcium gluconate or calcium chloride
249
This tocolytic class causes direct stimulation of B-adrenergic receptors in uterine smooth muscle, increases cAMP, and causes uterine relaxation
Beta-adrenergic agonists
250
Two types of beta-adrenergic agonists
Terbutaline, ritodrine
251
Side effects of this drug class = nausea, vomiting, restlessness, hyperglycemia, hypokalemia, acidosis, tachycardia, arrhythmias, pulmonary edema, delusional anemia
Beta-adrenergic agonists
252
Beta adrenergic agonists can also cause ___; incidence in 1-5% of patients receiving this tocolytic therapy
Beta agonist pulmonary edema
253
Risk factors for beta agonist pulmonary edema = ___ (increased/decreased) IVF administration; ___ gestation; tocolysis > ___ hours; concomitant ___ therapy; ___ion; ___kalemia; undiagnosed ___ disease
Increased IVF administration; multiple gestation; tocolysis > 24 hours; concomitant Mg therapy; infection; hypokalemia; undiagnosed heart disease
254
Multiple gestation—mortality of the ___ (first/second) twin is greater
Second twin
255
Pre-term labor complicates ___-___% of multiple gestation
40-50%
256
Vaginal birth is possible for most twin pregnancies—T/F?
True
257
If twin A is in breech position, C/S is a must and vaginal delivery is not possible—T/F?
True
258
Twin B requires monitoring until delivery is complete—T/F?
True
259
If twin A is not breech and twin B is breech, vaginal delivery is possible; if twin A is breech, C/S is required—T/F?
True
260
What local is preferred to be used d/t its rapid onset?
2-chloroprocaine 3%
261
Uterine ___ may be required for internal manipulation of fetus
Uterine relaxation
262
What is this describing?—sudden abdominal pain despite functional epidural; vaginal bleeding; hypotension; cessation of labor; fetal distress
Uterine rupture
263
Fetal distress is the most reliable sign of uterine rupture—T/F?
True...this is when fetal monitor will flat line
264
With uterine rupture, you should expect massive ___
Hemorrhage
265
Increased risk of ___ with uterine rupture
Postpartum hemorrhage
266
Fetal presentation is the most dependent or “presenting” part of the infant—T/F?
True
267
Most common fetal lie =
Longitudinal over transverse
268
Greatest chance of uncomplicated vaginal delivery = ___ presentation, ___ C-spine (chin to chest), ___ anterior (face down)
Vertex, flexed C-spine, occiput
269
(3) types of breech presentation:
- Complete breech
- Incomplete breech
- Frank breech
270
Complete breech =
Feet first
271
Incomplete breech =
One foot down, one foot up
272
Frank breech =
Butt first
273
Over 90% of breech infants are delivered vaginally—T/F?
False—delivered by c-section
274
___ lie is an absolute indication for a c-section
Transverse
275
Post maturity = gestation beyond ___ weeks; risks often evident at ___-___ weeks
Beyond 42 weeks; risks evident at 40-41 weeks
276
Post maturity causes ___ (increased/decreased) UBF and fetal ___
Decreased UBF and fetal distress
277
Post maturity—umbilical cord ___ may occur d/t oligohydramnios (low amniotic fluid)
Compression
278
Post maturity—___ staining of amniotic fluid may occur
Meconium
279
Post maturity = increased incidence of ___ and shoulder ___
Macrosomia and shoulder dystocia
280
Anesthetic considerations for post maturity—___ analgesia and preparations for ___ d/t cephalopelvic disproportion
Epidural analgesia and prep for C/S
281
Umbilical cord accidents—___ = cord prolapse through cervix, compressed; 10 minute window before fetal compromise
Prolapsed cord
282
Monoamniotic twins share one ___ and ___; risk of cord ___
Share one placenta and amniotic sac; risk of cord entanglement
283
Short cord < 30 cm risks ___
Compression, constriction, rupture
284
Long cord > 72 cm risks cord ___
Entanglement
285
Anesthesia for C/S—___ anesthesia is most common
Regional
286
Indications for ___ for C/S = acute severe fetal distress with no time for block; non-functioning epidural catheter; parturient has contraindication to regional block (i.e.: coagulopathy); regional block inadequate; patient refusal of block
General anesthesia
287
Limit time between uterine incision and delivery to less than ___ minutes
3 minutes
288
Consider ___ if patient is not a stat C/S and regional is not an option
Awake fiberoptic intubation
289
Aspiration prophylaxis for parturients: (3) drugs
- Sodium citrate (antacid)
- Ranitidine (Zantac)
- Reglan
290
This medication raises gastric pH; should be given to all patients prior to C/S, whether they are receiving general or regional anesthesia
Sodium citrate
291
Ranitidine (Zantac) is a ___
H2 blocker
292
This medication decreases gastric volume within minutes after administration
Reglan
293
Parturients for elective procedures should be NPO for ___ hours
6
294
A parturient is always considered to have a ___
Full stomach! Even after being NPO for 6+ hours
295
What position is mandatory for all cases?
Uterine displacement
296
At term, O2 consumption is increased ___-___%; this is accompanied by a decrease in ___
20-30%; decrease in FRC
297
Increased O2 consumption + decreased FRC in pregnancy results in a faster rate of ___ during apnea
Desaturation
298
The key is to increase oxygen content of the lungs by having the patient breathe 100% O2 with a tight mask fit for at least ___ minutes
3
299
Propofol dose in parturient
1.5-2 mg/kg
300
Ketamine dose in parturient
1.1-5 mg/kg
301
This drug is useful in the face of maternal hemorrhage as it supports BP and decreases the risk of bronchospasm
Ketamine
302
Side effects of ketamine = ___tension and ___
Hypertension and dysphoria
303
2 induction agents that are NOT commonly used for GA in parturients = ___ and ___
Midazolam and etomidate
304
Versed causes more ___ than other agents
Neonatal depression than other agents; can be given to mom after the baby is born
305
Etomidate may cause transient ___ suppression in the neonate
Adrenal
306
___ induction is mandatory
Rapid sequence
307
Any relaxant is safe in pregnancy, as their ___ charged nature significantly limits placental transfer
Hydrophilic
308
If mom can’t receive succs (i.e.: history of malignant hyperthermia), then use high dose ___ for rapid sequence induction
Roc
309
There is no correlation between neonatal depression and the interval between ___ and delivery
Anesthetic induction
310
The uterine incision to delivery interval does make a difference, possibly d/t uterine artery spasm—T/F?
True—time between uterine incision/delivery should be less than 3 minutes
311
If an epidural is dosed for C/S and does not produce an adequate surgical block, then a general anesthetic may be required as the risk of a total spinal is ten-fold higher in this condition—T/F?
True
312
Greatest cause of death in parturients undergoing regional anesthesia for C/S = ___
Local anesthetic toxicity
313
If block extends to T1, a reduction in ___ and ___ may be seen
Heart rate and contractility (because cardiac accelerators = T1-T4)
314
Epidural has no effect on inspiration—T/F?
True
315
Expiratory pressures and flows are ___ (increased/decreased) in proportion to decreased abdominal muscle strength from epidural
Decreased
316
A sensory block above T2 often gives patients a sense of ___
Dyspnea
317
Epidural—dose catheter ___ and in ___; ___ before each dose
Slowly and in increments; draw back syringe before each dose
318
Sodium bicarbonate will slow the onset of lidocaine or 2-chloroprocaine—T/F?
False—will speed onset
319
The ideal block height is somewhere between ___-___
T4-T8
320
10-50% of patients with epidurals have ___ pain
Breakthrough pain
321
Treatment options for breakthrough pain—a bolus of ___ cc of local; epidural or IV ___; ___ (think inhalation agent); ___ IV—keep total dose below 1 mg/kg, ~10 mg at a time to minimize dysphoria
bolus of 5 cc of local; epidural or IV fentanyl; nitrous oxide; ketamine IV
322
If epidural is clearly inadequate, convert to ___
General anesthetic
323
Intravascular injection is not a concern with spinals—T/F?
True
324
Maternal hypotension is more common with spinals than epidurals—T/F?
True
325
Laboring women have less hypotension with spinals than non-laboring women—T/F?
True
326
Treatment of maternal hypotension—___ was the drug of choice, but was found to increase the likelihood of fetal ___
Ephedrine was the drug of choice, but was found to increase the likelihood of fetal acidosis
327
Treatment of maternal hypotension—___ is now considered the drug of choice by many practitioners
Phenylephrine
328
If a mom is already bradycardic, ___ may not be the best choice for treatment of maternal hypotension
Phenylephrine
329
Can use ___ to maintain mom’s HR/placental perfusion to the baby
Combination of ephedrine + phenylephrine
330
This drug takes a long time to work, has long duration, and is unreliable
Tetracaine
331
This drug is short acting and has had reports of transient neurological symptoms; not the best choice for spinal/epidural
Lidocaine
332
This is the best choice of drug for spinal/epidural in parturients; combines quick onset with intermediate duration
Bupivacaine
333
Can give ___ via epidural after baby is delivered
Duramorph (morphine)
334
Addition of duramorph provides long-acting analgesia (12+ hours), but increases risk of delayed ___ and produces side effects such as ___ and ___
Risk of delayed respiratory depression; nausea and pruritis
Important to consider risk of respiratory depression in moms with sleep apnea
335
Fentanyl and duramorph can cause severe ___
Facial itching
336
Once baby is delivered, administer pitocin ___ units in ___ cc IV bag
30 units in 500 cc IV bag
337
Run pitocin as a bolus dose—run it at ___ ccs/hr for first 30 mins, then decrease to ___ ccs/hr for remainder
334 ccs/hr for first 30 mins, then decrease to 95 ccs/hr for remainder
338
If pitocin is given too fast, can cause a ___ response
Hypertensive
339
(3) common non-obstetric surgical procedures in the parturient:
- Appendectomy
- Cholecystectomy
- Kidney stones
340
No anesthetic agent is a proven teratogen in humans—T/F?
True
341
Limit ___ use in pregnant patients because it has been shown to have a teratogenic effect in rats during the first trimester
Nitrous oxide
342
Anesthetic management in the parturient should be directed to: avoidance of ___emia, ___tension, ___osis; maintain ___ in the normal range; minimize effects of ___
Avoidance of hypoxemia, hypotension, acidosis; maintain PaCO2 in the normal range; minimize effects of aortocaval compression
343
Fetal HR and uterine activity should be monitored in women at ___ weeks GA or greater
20
344
___ have been linked to congenital anomalies and should not be used in pregnant patients
Benzos
345
Avoid ___ as it may interfere with B12 metabolism
Nitrous oxide
346
Elective procedures should be postponed until at least ___ weeks after delivery
6 weeks
347
The physiological effects of pregnancy are usually well established by 20 weeks gestational age—T/F?
True
348
Volatile agents may suppress preterm labor—T/F?
True
349
Hyperthyroidism in pregnancy—potential for thyroid storm—high ___, ___cardia, agitation, severe ___
High fever, tachycardia, agitation, severe dehydration
350
Anesthetic considerations for hyperthyroidism—propranolol may exacerbate ___ following spinal; consider ___ for elective c-section
Hypotension; consider epidural for elective c-section
351
Hyperthyroidism in pregnancy—anticipate exaggerated responses to ___ d/t hypersensitive myocardium, titrate carefully
Pressors
352
Pheochromocytoma secretes excessive ___
Catecholamines—epi and norepi
353
Pheochromocytoma can mimic ___
Preeclampsia
354
Pheochromocytoma and elective c/s—pre-op therapy with ___ blockers, followed by ___ blockers
Alpha blockers, followed by beta blockers
355
Pheochromocytoma—avoid beta blockade without prior alpha blockade because of risks with ___
Unopposed alpha stimulation (severe HTN)
356
Bronchial asthma may improve during pregnancy d/t bronchodilation—T/F?
True
357
General anesthesia should be avoided if possible in pregnant asthmatics because ETT can trigger ___
bronchospasm
358
Avoid ___ in pregnant asthmatics because they can cause increased sensitivity to histamine that can cause spasm
H2 blockers (i.e.: cimetidine, ranitidine)
359
Use ___ for induction in pregnant asthmatics because it causes bronchial relaxation
Ketamine
360
Avoid ___ in pregnant asthmatics because it can cause airway irritation
Desflurane
361
For pregnant paraplegics, early epidural analgesia should be initiated to prevent hyperreflexia—T/F?
True
362
Avoid what NMB in paraplegics d/t risk of hyperkalemia?
Succinylcholine
363
Pregnancy has no effect on progression of MS—T/F?
True
364
Slight increased risk for MS relapse during pregnancy—T/F?
True
365
MS and neuraxial anesthesia—use lowest concentration and volume of local anesthetic that can achieve analgesia—T/F?
True
366
MS and anesthesia—succinylcholine should be avoided with severe musculoskeletal involvement—T/F?
True
367
Brain tumor and pregnancy—avoid ___ and ___
Spinal (dural puncture) and epidural (risk for accidental dural puncture)
368
Brain tumor and pregnancy—bilateral ___ sympathetic blocks for 1st stage of labor, ___ block for 2nd stage labor
Bilateral lumbar sympathetic blocks for 1st stage of labor; pudendal block for 2nd stage labor
369
Brain tumor and pregnancy—if having C/S, can consider epidural but will usually use GETA with generous narcotic doses to blunt reflexes during laryngoscopy and prevent sudden increases in ___ and ___
BP and ICP
370
Pseudotumor cerebri = ___
Benign intracranial hypertension
371
Pseudotumor cerebri is not ___, so epidural or spinal block is OK
Not mass-related
372
Epilepsy and pregnancy—there is evidence of increased risk of convulsions with use of local anesthetics—T/F?
False—no evidence to support this
373
Myasthenia gravis and pregnancy—___ are contraindicated
Tocolytics—i.e.: magnesium sulfate, beta adrenergics—ritodrine, terbutaline
374
IV dosages of myasthenia gravis medications are given in ratio of ___:___ oral dose
30:1
375
What is the preferred anesthetic technique for myasthenia gravis parturients?
Regional is preferable to general anesthesia
376
If GETA is required for parturient with myasthenia gravis, keep doses ___
To absolute minimum
377
___ MAC is usually adequate for patients with myasthenia gravis
1/2
378
Parturients with myasthenia gravis are highly sensitive to ___
NMBs
379
Intubation doses of NMBs for parturients with myasthenia gravis are typically ___ to ___ normal
1/2 to 1/3 normal
380
Parturients with myasthenia gravis are more receptive to effects of ___ and ___
Opioids and local anesthetic agents
381
What is this describing?—profound muscle weakness, respiratory failure, loss of bowel/bladder function, disorientation, diplopia
Cholinergic crisis
382
Treat cholinergic crisis with ___
IV or IM atropine
383
HgbAS patients = ___zygous, sickle ___, usually ___ with pregnancy
Heterozygous, sickle trait, usually no problems with pregnancy
384
HgbSS or HgbSC patients = ___zygous, more severe ___, higher incidence of ___
Homozygous, more severe anemia, higher incidence of preeclampsia
385
General considerations for sickle cell disease and pregnancy = avoid ___
Sickle cell crisis
386
How to avoid sickle cell crisis?—avoid ___ia, ___tension, de___, ___thermia, and ___osis
Avoid hypoxia, hypotension, dehydration, hypothermia, and acidosis
387
What kind of anesthesia is preferred for parturients with sickle cell disease?
Epidural preferred
388
Sickle cell/epidural—give ___ prior to block
Adequate bolus of warmed IVF
389
Sickle cell and C/S—___ preferred d/t decreased risk of hypotension and can be used post-op for pain control if patient has sickle cell crisis
Epidural
390
If GA is necessary for parturient with sickle cell disease, follow usual precautions with special attention to avoiding ___ and ___
Hypothermia and hypoxia
391
VWD—neuraxial blockade is a relative contraindication, although can be considered if coagulation times are monitored and appropriately treated—T/F?
True
392
Factor V Leiden—if taking prophylactic LMWH dose, hold > ___ hours before block
> 12 hours
393
Factor V Leiden—if on therapeutic LMWH dose, hold > ___ hours before block and consider anti-Xa heparin assay
> 24 hours
394
Deficiency of proteins C and S lead to ___coagulability, recurrent ___ and ___
Hypercoagulability, recurrent DVT and PE
395
Patients with protein C and S deficiency may be on heparin therapy, so neuraxial blockade should be timed appropriately—T/F?
True
396
Main consideration for parturients with RA =
Difficult airway
397
___ anesthesia is preferred for patients with RA but is sometimes not possible d/t joint deformities
Regional
398
If regional is not possible for patient with RA, do ___ to secure airway prior to induction
Awake fiberoptic intubation
399
Lupus in pregnancy—check EKG for ___ or ___ changes
Prolonged PR or T wave changes
400
Lupus in pregnancy—___ disorders are common
Valve
401
Addiction and pregnancy—risk for ___, ___ labor, and ___ weight
Withdrawal, pre-term labor, and low birth weight
402
Alcoholic mothers have increased risk of ___
Hemorrhage
403
Ampethamines cause catecholamine ___, so mom will have limited response to indirectly acting sympathomimetics, i.e.: ___
Catecholamine depletion; limited response to ephedrine
404
Ampethamines cause ___ (increased/decreased) MAC for general anesthesia
Increased
405
Increased volatile agents used for patients who take amphetamines [d/t increased MAC] can increase the risk for uterine atony—T/F?
True
406
Cocaine is a vaso___ that causes ___ (increased/decreased) uteroplacental blood flow
Vasoconstrictor that causes decreased uteroplacental blood flow
407
Cocaine and pregnancy—patient can experience severe ___tension, ___cardia
Severe HTN, tachycardia
408
Chronic cocaine use can cause ___penia
Thrombocytopenia—increased risk for bleeding
409
Cocaine can decrease plasma ___ and prolong the duration of ___ and ___
Decrease plasma cholinesterase and prolong the duration of ester locals (i.e.: 2 chloroprocaine) and NMBs—succs
410
There is little evidence to suggest that HIV or antiretroviral drugs increase the incidence of pregnancy complications, or that pregnancy alters the course of infection—T/F?
True
411
What are the two most common medical problems of pregnancy?
Diabetes and hypertension
412
Gestational diabetes refers to DM that is first diagnosed in ___
Pregnancy
413
Gestational diabetes is more prevalent in the ___ and ___ trimesters
Second and third
414
After delivery, most parturients return to normal glucose tolerance—T/F?
True
415
Recurrence rate of gestational diabetes with subsequent pregnancies is 52-68%—T/F?
True
416
What is the best way to prevent fetal structural abnormalities from gestational diabetes?—initiation of early ___
Initiation of early glycemic control
417
Pregnant women with gestational diabetes may develop ___ which results in delayed emptying
Gastroparesis
418
Gastroparesis = risk for ___
Aspiration
419
Gestational diabetics have even more fluid in their stomachs than the average parturient—T/F?
True
420
Stomach should be decompressed in parturients with gestational diabetes before induction of anesthesia—T/F?
True
421
Patients who are diabetic take less time to clear local anesthetic from their bodies—T/F?
False—diabetics take longer to clear local anesthetic from their bodies
422
Uteroplacental blood flow index is reduced by ___-___% in gestational diabetics, even more so with poorer glucose control
35-45%
423
Diabetic keto acidosis—plasma glucose > ___, HCO3 < ___, pH < ___, acetone ___
Plasma glucose > 300, HCO3 < 15, pH < 7.30, acetone positive
424
In diabetic keto acidosis, ketones cross the placenta and ___ (increase/decrease) fetal oxygenation
Decrease
425
Biggest issue with obese parturients = difficulty with ___ and problems with placement of ___
Difficulty with intubation and problems with placement of neuraxial anesthesia
426
Studies have shown that minimum local anesthetic concentration for obese women was 41% LOWER than non-obese women—T/F?
True—there is greater distribution of epidural local anesthetic within the epidural space in obese women
427
Hypertension remains a leading source of maternal mortality—it is the ___ leading cause of maternal mortality, after ___ and ___ injuries
It is the third leading cause of maternal mortality, after thromboembolism and non-obstetric injuries
428
Maternal DBP > ___ is associated with increased risk of placental abruption and fetal growth restriction
Maternal DBP > 90
429
4 categories of HTN in pregnancy:
- Chronic HTN
- Pregnancy induced HTN
- Preeclampsia-eclampsia
- Preeclampsia superimposed on chronic HTN
430
Pregnancy induced hypertension—sustained BP increase to SBP > ___ or DBP > ___
SBP > 140 or DBP > 90
431
Pregnancy induced HTN has no renal or systemic involvement—T/F?
True
432
PIH resolves ___ weeks postpartum
12
433
PIH may evolve to ___
Preeclampsia
434
Preeclampsia is new onset HTN after ___ weeks gestation
20
435
Preeclampsia resolves within ___ hours postpartum
48
436
Maternal risk factors for preeclampsia—age younger than ___ or older than ___
Younger than 18 or older than 35
437
Headache, visual disturbances, and epigastric pain are seen in severe preeclampsia—T/F?
True
438
Mild preeclampsia—systolic BP ___ to ___; diastolic BP ___ to ___
Systolic 140-160; diastolic 90-110
439
Severe preeclampsia—systolic BP > ___; diastolic BP > ___
Systolic > 160; diastolic > 110
440
Preeclampsia is thought to be due to increased levels of thromboxane-A2 relative to prostaglandin in parturients—T/F?
True—thromboxane-A2 is a vasoconstrictor (causes vasospasm that leads to symptoms of preeclampsia)
441
Airway edema in preeclamptic patients can make intubation difficult—T/F?
True
442
Use ___ ETT in pregnant patients
6.5
443
GFR and CrCl ___ (increase/decrease) in preeclampsia; BUN ___ (increases/decreases) in preeclampsia
GFR and CrCl decrease; BUN increases
444
Overhydrating in preeclampsia can lead to ___
Pulmonary edema—be careful with hydration!!!
445
Severe PIH or preeclampsia can be complicated by ___
HELLP
446
HELLP = ___
Hemolysis, Elevated Liver enzymes, Low Platelets
447
Uterine activity is ___ (increased/decreased) in preeclampsia; the uterus is hyperactive/sensitive to ___; preterm labor is ___
Uterine activity is increased in preeclampsia; uterus is hyperactive/sensitive to oxytocin; preterm labor is common
448
Uterine/placental blood flow is decreased by 50-70% in preeclampsia—T/F?
True
449
Leading cause of maternal death in PIH is ___
Intracranial hemorrhage
450
DIC is uncommon as a primary manifestation of preeclampsia—T/F?
True
451
Placental abruption presents as ___
Rock hard abdomen...abdomen is full of blood and baby is not being perfused
452
Treatment of preeclampsia = ___
Mag sulfate
453
Plasma level of mag for treatment of preeclampsia should be between ___
4-6 mmol/L
454
Signs of mag toxicity—prolonged PR, widened QRS = ___-___ mEq/L
5-10 meq/L
455
Signs of mag toxicity—depressed tendon reflexes = ___-___ meq/L
11-14 meq/L
456
Signs of mag toxicity—SA, AV node block, respiratory paralysis = ___-___ meq/L
15-24 meq/L
457
Signs of mag toxicity—cardiac arrest > ___ meq/L
> 25 meq/L
458
Treat mag sulfate toxicity with ___ or ___
Calcium gluconate or calcium chloride
459
Best anesthetic technique for preeclamptic patients = ___
Epidural
460
Epidurals in preeclampsia may reduce ___ and ___; may improve ___ blood flow
May reduce vasospasm and HTN; may improve uteroplacental blood flow
461
Epidural for preeclampsia reduces the risk of ___ complications
Airway
462
Preeclampsia—in patient receiving mag sulfate, ___ activity is potentiated; patient has enhanced sensitivity to ____
Succs activity; enhanced sensitivity to NMBs
463
Mag sulfate blunts response to ___ and inhibits ___ release after sympathetic stimulation
Blunts response to vasoconstrictors and inhibits catecholamine release after sympathetic stimulation
464
HELLP syndrome symptoms—___, ___ pain, ___/___
Malaise, epigastric pain, nausea/vomiting
465
HELLP syndrome is usually ___
Self-limiting
466
HELLP syndrome—hemostasis is NOT problematic unless platelets are < ___
< 40,000
467
HELLP syndrome—rate of fall in platelet count is important; regional anesthesia is contraindicated if fall in platelet count is ___
Sudden
468
HELLP syndrome—platelet count returns to normal within ___ hours of delivery
72
469
Definitive cure of HELLP syndrome = ___
Delivery of fetus
470
What is this?—painless vaginal bleeding is the most common presentation
Placenta previa
471
Placenta previa is termed a “complete previa” when the cervical os is ___ by placenta
Entirely covered
472
All patients with vaginal bleeding are considered to have a placenta previa until proven negative by ultrasound—T/F?
True
473
Patients with a history of previous C/S and a current placenta previa are at very high risk of placenta ___
Accreta
474
What is this?—placenta does not penetrate entire thickness of myometrium
Placenta accreta
475
What is this?—placenta invades further into the myometrium
Placenta increta
476
What is this?—placenta attaches completely through the myometrium, into serosa, and potentially outside of uterus, with invasion into surrounding structures (i.e.: bladder, colon)
Placenta percreta
477
Which placental abnormality is the worst?
Placenta percreta
478
Treatment of placenta accreta = planned ___ and ___; prepare for ___ anesthesia
C/S and abdominal hysterectomy; prepare for general anesthesia
479
What is this?—premature separation of a normal placenta; painful vaginal bleeding
Abruptio placentae
480
What is the most common cause of intrapartum fetal death?
Abruptio placentae
481
Most common presentation of this complication is sudden profound fetal distress with continuous severe abdominal pain; often, an epidural will NOT mask this pain
Uterine rupture
482
Postpartum hemorrhage is considered present when postpartum blood loss exceeds ___ ccs
500
483
(3) causes of postpartum hemorrhage: uterine ___, ___ placenta, uterine ___
Uterine atony, retained placenta, uterine inversion
484
Treatment of uterine atony = ___, ___, or ___
Oxytocin, methylergonovine, prostaglandin F2-alpha
485
Do not give methylergonovine ___ because it can cause hypertension and vasoconstriction
IV...give 0.2 mg IM
486
Do not give ___ to asthmatic patients because it will cause bronchospasm
Prostaglandin F2-alpha
487
Retained placenta and uterine inversion require ___ anesthesia
General
488
If patient is hypovolemic, ___ is not a good idea
Neuraxial block
489
Amniotic fluid embolism is AKA ___
Anaphylactoid syndrome of pregnancy
490
Amniotic fluid embolism can occur during labor, delivery, C/S, or even postpartum—T/F?
True
491
Mechanism of amniotic fluid embolism is thought to involve entry of amniotic fluid into ___ through breaks in uteroplacental membrane
Maternal circulation
492
Mortality of amniotic fluid embolism is ~85%—T/F?
True
493
Chest compressions are nearly worthless if the baby is still inside mom because aortocaval compression makes supine resuscitation impossible and compressions don’t work well in the lateral position—T/F?
True
494
The diagnosis of AFE rests on demonstrating ___ in maternal circulation (often at autopsy)
Demonstrating fetal elements
495
Baseline FHR = ___-___ bpm
120-160
496
Decrease in FHR may indicate ___
Asphyxia
497
Absence of short- and long-term variability may indicate ___
Fetal distress
498
PH < 7.20 in fetus may be associated with ___
Depressed neonate, needs oxygen
499
The Apgar score rates what (5) things:
- Respiration
- Reflexes
- Pulse
- Skin color of body and extremities
- Muscle tone
500
Get Apgar scores at ___ and ___ minutes
1 and 5 minutes
501
If 5 minute score is less than 7, repeat Apgar assessment every ___ minutes until ___ minutes have passed or two successive scores are greater than or equal to ___
Repeat every 5 minutes until 10 minutes have passed or two successive scores are > or equal to 7
502
Survival of newborn is unlikely if Apgar score is 0 at 10 minutes—T/F?
True
503
Anesthesia’s primary responsibility is the ___
Mother
504
Resuscitation of the neonate is primarily the responsibility of the ___
Neonatal care team
505
Fetal respiratory rate = ___-___ breaths per min
30-60
506
Pulse should be > ___ bpm
> 100
507
If HR < 60 or 60-80 and not rising, start ___ at ___ bpm and ___
Start chest compressions at 120 bpm and intubate
508
If baby’s BP is low, can give fluid—___ml/kg of LR or NS
10 ml/kg
509
Rule out ___glycemia, ___magnesemia, or ___calcemia as causes of hypotension
Hyperglycemia, hypermagnesemia, or hypocalcemia as causes of hypotension
510
Medications are indicated if heart rate remains < ___ bpm with adequate ___ and ___ for 30 seconds
HR remains < 60 bpm with adequate ventilation with 100% O2 and chest compressions for 30 seconds
511
Can give meds via ___ vein, ___ vein, or ___ tube
Peripheral vein, umbilical vein, or ETT
