High Risk OB Flashcards by Colleen Storrie-Gaul

Once uterine incision is made if fetal problems are occurring a higher incidence of low APGAR scores and acidosis are related to time it takes to get fetus out, this occurs if it takes longer than?

3 minutes

180 seconds

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Where does central catecholamine release occur?

Periventricular and paraventricular tissue and dorsal medial medulla and throughout the brain

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Neuraxial anesthesia for asthma patients has minor effects on which effort?

Inspiratory

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Expiratory function is more affected by neuraxial because of?

More intense motor block affects:
ABD wall muscles
Cough strength

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Some prefer epidural over spinal with severe asthma patients because?

Not as much decrease in epinephrine secretion

-helps bronchodilation

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What can be used to help dry up secretions and bronchodilation in asthma patients?

Atropine

Glycopyrrolate

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For GA with asthma patients, what is the drug of choice?

Ketamine

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What is considered to be the most important factor in producing acute airway obstruction in asthma patients?

Constriction of airway smooth muscle

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Definition of asthma

Reversible airway obstruction
Airway inflammation
Airway hyper responsiveness

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Other mechanisms of acute airway obstruction in asthma patients

Neural imbalance between constricting and dilation influences
Airway inflammation
Airway epithelial destruction > changes it’s function

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Neural components of asthma

PNS
SNS
Alpha adrenergic system
Non-adrenergic non-cholinergic system

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What system is the most predominant constrictor of the airway in asthma patients?

Parasympathetic nervous system

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What is the dilator in the non-adrenergic, non-catecholamine system (NANC)?

Nitric oxide

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What is the leading cause of maternal mortality?

DVT & PTE

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Pregnant women vs non-pregnant women have a ____ time greater risk of thrombotic event

5 times greater

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When is the highest risk for a pregnant women’s thrombotic event?

Immediately postpartum

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How much does a c-section increase the risk of a thrombotic event?

Doubles the risk

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What are the 2 most important risk factors for thromboembolic events in pregnancy?

Previous history of thromboembolism

Diagnosis of thrombophilia

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Which thrombophilia increases the risk for VTE in pregnancy the most?

Homozygous factor V Leiden mutation

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What are the most modifiable risk factors for thromboembolic event

Antenatal
Immobilization
Obesity

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Physical s/sx of PE

SOB
Anxiety
Palpitations
CP
Cyanosis
Diaphoresis
Coughing +/- blood
Crackles
Decreased breath sounds
Tachycardia
Tachypnea
JVD
Split 2 heart sounds
Right axis shift
ST segment abnormalities 
T wave inversion

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Most air emboli are small with no sequelae, but emboli larger than _____ may be lethal

200-300 mL

-or 3-5ml/kg

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When is the most common time of air entrainment with c-section?

Immediately after placental separation

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What are the manifestations of massive VAE?

Hypotension
Hypoxemia
Dyspnea
Arrhythmia
Chest pain
Cardiac arrest

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During neuraxial anesthesia how can a VAE present?

Hypoxemia Dyspnea Chest pain during uterine repair

During GA what suggests VAE?

Hypoxemia | Slight decrease in end-tidal CO2

What is the treatment for VAE?

Flood sx field with saline Drop ABD lower than heart Vasopressors CPR Deliver infant 100% O2 (turn off nitrous if in use- grows air embolus) Avoid PEEP and valsalva maneuvers (can cause paradoxical embolism)

During what stage of labor does amniotic fluid embolus usually occur?

Second stage | -during labor or after delivery of placenta

S/Sx of amniotic fluid embolus

``` Sudden onset chills Shivering Diaphoresis Tachypnea Cyanosis CV collapse DIC ```

What other conditions appear just like amniotic fluid embolus (AFE)?

Placental abruption Uterine Rupture Anaphylaxis

What is the classic triad of AFE?

``` Acute hypoxia (respiratory distress) Hemodynamic collapse (CV collapse) Coagulopathy without precipitating cause, may not manifest for several hours ```

Risk factors of AFE

``` Meconium in fluid Older age Abnormal presentation Placental abruption Eclampsia Multiple gestation Induction of labor Artificial rupture of membranes Operative delivery ```

Test/diagnosis of AFE?

No specific one, often diagnosed after death

What are the 2 phases of AFE?

Stage 1: CV collapse within 30 minutes of delivery | Stage 2: Hemorrhage and DIC

What is often the first sign of AFE?

Respiratory failure due to RV failure from severe pulmonary vasoconstriction

Treatment for AFE?

``` Intubate - 100% O2 CPR - must deliver fetus to be effective Inhaled nitric oxide or prostacyclin Cardiopulmonary bypass Aggressive volume and press or support Order blood, FFP, Cryo RV assist device ECMO ```

What is the AOK protocol? What is it used to treat?

Atropine 1mg Ondansetron 8mg Ketorolac 30mg Amniotic fluid embolus

What does atropine do for AOK protocol?

Blocks vagal responses Prevents systemic hypotension because it prevents bradycardia Decreases vasoconstriction in pulmonary vasculature

What does Zofran do in AOK treatment?

Serotonin antagonist Help with vagotomy Also prevents CV collapse

What does Ketorolac do in AOK treatment?

Directly inhibits thromboxane > stopping coagulation cascade and prevent DIC

AOK shows profound hemodynamic recovery with complete neurological recovery within how long?

2 minutes

After cardiac arrest what has the largest impact on saving mom and fetus avoiding severe neurological injury

CPR

If mother survives what should be expected?

Hemorrhage and DIC | +/- Emergency hysterectomy

What is cervical insufficiency?

Inability of the cervix to hold a pregnancy in the uterus through the second trimester in the absence of labor

List 4 causes of cervical insufficiency

Congenital disorders Acquired Previous D&C Loop electrical excision procedure (LOOP)

When is transvaginal cervical cerclage done?

12-18 weeks | -more successful if done before problems

What is the anesthetic of choice for cervical cerclage?

SAB

What position is used for cerclage placement and why?

Steep trendelenburg | -to help get membranes out of the way

What needs to be avoided during cerclage placement?

Coughing and vomiting | -give meds to avoid

Symptoms of cervical insufficiency

``` Altered vaginal discharge Lower abdominal or back pressure or discomfort Vaginal fullness Urinary frequency Can be asymptomatic ```

When is diagnosis of cervical insufficiency definitive?

If delivery occurs in the second trimester before 24 weeks gestation in the absence of bleeding, infection, or labor as the initial symptom -she says when herniated fetal membrane is seen or palpated during second trimester

What provides proficient certainty of cervical insufficiency?

Cervical dilation or prolapse of membranes through the cervix in the absence of other findings or symptoms

Why is a spinal preferred with cerclage? (She says)

Faster onset q

GA may need to be performed for cerclage if what?

Uterine relaxation is needed

Is dantrolene safe in pregnancy

Yes

Trial of labor after c-section/vaginal birth after c-section is advised to be

In the hospital

What anesthetic should be avoided in epilepsy?

Ketamine

Multiple Sclerosis relapse rate is 3x higher when?

First 3 months postpartum

With intrauterine fetal death what develops in the mother if the fetus stays in how long?

DIC | More than 1 month

HIV/AIDS may have difficult intubation why?

Pharyngeal lymphatic hypertrophy

Myasthenia Gravis prolongs what stage of labor and why?

Second stage | Muscle weakness

What medications should be avoided and used cautiously in myasthenia gravis patients?

Avoid Magnesium | Overly sensitive to ND-NMB

Why should Mg be avoided in myasthenia gravis patients?

It can precipitate a myasthenic crisis

When is neuraxial anesthesia for c-section not the preferred choice in MG patients?

When myasthenia gravis patient has significant bulbar involvement or respiratory compromise

What procedure decreases myasthenia gravis exacerbations and exerts a favorable outcome in pregnancy?

Thymectomy

Why and how long should a woman delay pregnancy after initial myasthenia gravis diagnosis?

Exacerbations occur more frequently in the first year after diagnosis Delay for 1-2 years

What stage of labor does myasthenia gravis affect, why?

Second stage First stage is smooth muscle in the uterus (not affected by MG) Second stage often requires use of striated muscle

Myasthenia gravis symptoms in neonate

``` Poor sucking Generalized hypotonia Difficulty feeding Feeble cry Ptosis Respiratory distress ```

When do myasthenia gravis symptoms develop in the newborn and when do they usually abate?

Develop within the first 12-48 hours | Abate within 2-4 weeks as antibodies are metabolized

Why may succinylcholine be prolonged in myasthenia gravis patients?

Decrease in plasma cholinesterase from their MG treatment with anticholinesterases

What genital herpes outbreak requires a c-section for delivery to prevent transmission to baby?

Primary outbreak

When is vaginal delivery and regional anesthesia acceptable with a genial herpes patient?

Secondary infection and if cervical cultures are negative

What is the major concern with genital herpes and fetus?

Neonatal HSV is a life-threatening infection with the potential for permanent CNS sequelae -encephalitis

Why med/anesthetic technique increases the recurrence of oral HSV?

Spinal or epidural morphine | -avoid using

Risk of maternal death is greater with what anesthetic?

GA vs neuraxial

High Risk OB Flashcards

(75 cards)