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APEX-across the lifespan > LIFESPAN-obstetrics 9--18 > Flashcards

LIFESPAN-obstetrics 9--18 Flashcards

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1
Q

2 things fetal heart rate indirectly measures

A
  1. Fetal hypoxia

2. Fetal acidosis

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2
Q

Fetal oxygenations is a function of what 2 things

A
  1. uterine bf

2. placental bf

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3
Q

What are 3 fetal responses to decreased oxygenation

A
  1. peripheral vasoconstriction
  2. HTN
  3. baroreceptor-mediated reduction in HR
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4
Q

What are the parameters for the following fetal heart rates:
Normal=
Bradycardia=
Tachycardia=

A 
Normal= 110-160
Bradycardia= <110
Tachycardia= >160
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5
Q

What are 2 causes of fetal bradycardia

A
  1. asphyxia

2. acidosis

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6
Q

What are 2 causes of fetal tachycardia

A
  1. hypoxemia

2. arrythmias

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7
Q

What are 2 maternal causes of fetal bradycardia

A
  1. hypoxemia

2. drugs that decrease uteroplacental perfusion

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8
Q

What are 5 maternal causes of fetal tachycardia

A
  1. fever
  2. chorioamnionitis
  3. atropine
  4. ephedrine
  5. terbutaline
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9
Q

Is fetal HR variability normal?

A

Yes

It should have a variability of 6-25 bpm

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10
Q

What are the 4 classes of fetal HR variability

A
  1. minimal <5 bpm
  2. moderate 6-25 bpm
  3. marked >25 bpm
  4. absent = worrisome
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11
Q

What are 6 factors that reduce fetal HR variability

A
  1. CNS depressant drugs
  2. Hypoxemia
  3. Fetal sleeps
  4. Acidosis
  5. Anencephaly
  6. Cardiac anomalies
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12
Q

What are the 3 types of fetal decelerations

A
  1. early
  2. late
  3. variable
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13
Q

What is a cause of early decelerations

Is there a risk of hypoxemia

A 
Cause = head compression that increases vagal tone (HR <20 bpm from baseline)
Hypoxemia = NO risk
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14
Q

How do early decelerations correlate with uterine contraction

A

Onset and offset parallel uterine contraction

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15
Q

What is a cause of late decelerations

Is there a risk of fetal hypoxemia

A

Cause = uteroplacental insufficiency

Hypoxemia = high risk, requires urgent fetal assessment

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16
Q

How do late decelerations correlate with uterine contraction

A

FHR falls after peak of contraction then returns to baseline after contraction

Occurs with each contraction

Gradual reduction of FHR

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17
Q

What are 4 maternal causes of late deceleration

A
  1. HoTN
  2. Hypovolemia
  3. acidosis
  4. preE
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18
Q

What is a cause of variable deceleration

Is there a risk of fetal hypoxemia

A

Cause = umbilical cord compression causing baroreceptor mediated reduction in FHR

hypoxemia = high risk, requires urgent fetal assessment

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19
Q

How do variable decelerations correlate with uterine contractions

A

No consistent pattern between FHR and contraction

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20
Q

How does fetal health affect recovery from variable decelerations

A

fetal compromise prolongs FHR recovery time

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21
Q

Mnemonic for fetal decelerations

A 
VEAL CHOP
Variable decels = Cord compression
Early decels = Head compression
Accelerations = Ok or give O2
Late decels = Placental insufficiency
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22
Q

What are 5 findings of Category 3 evaluation of FHR

A
  1. bradycardia
  2. absent baseline variability
  3. recurrent late decels
  4. recurrent variables decels
  5. sinusoidal pattern
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23
Q

What does category 3 evaluation of FHR suggest

A

abnormal fetal acid-base status with significant threat to fetal oxygenation

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24
Q

What does category 2 evaluation of FHR suggest

A

It cannot predict a normal or abnormal acid-base status

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25
What are 5 findings associated with category 2 evaluation of FHR
1. bradycardia w/o the absence of baseline FHR variability 2. Tachycardia 3. Variable variability 4. Absent or minimal acceleration with fetal stimulation 5. recurrent variable decels
26
What are fetal HR findings associated with category 1 evaluation
1. baseline HR between 110-160 2. moderate variability 3. accelerations absent or present 4. early decels absent or present 5. no later or variable decels
27
What are 6 fetal complications of premature delivery
1. respiratory distress syndrome 2. intraventricular hemorrhage 3. NEC 4. hypoglycemia 5. hypocalcemia 6. hyperbilirubinemia
28
What medication hastens fetal lung development in preterm labor when do they take effect and peak
Betamethasone (corticosteroids) Take effect = 18 hrs Peak = 48 hrs
29
What are tocolytics
drugs used to delay labor by suppressing uterine contraction
30
What is the goal for using tocolytics
allow time for corticosteroids to work for fetal lung maturity
31
What are 4 examples of tocolytic agents
1. beta-agonists 2. magnesium sulfate 3. CCBs 4. NO donors
32
What is the MOA of beta-agonists as tocolytics
They increase intracellular cAMP Protein kinase turns off myosin light-chain kinase, relaxing uterus Increased progesterone release
33
What are 4 side-effects of beta-agonist use as tocolytics
1. hyperglycemia from liver glycogenolysis 2. newborn at higher risk for hypoglycemia 3. Hypokalemia from intracellular K+ shifts 4. Beta2 agonists cross the placenta and increase FHR
34
Why is magnesium sulfate used as a tocolytic
It is a Ca++ antagonist which relaxes smooth muscle by turning off myosin light-chain kinase in vasculature, airway, and uterus
35
What effect does mag have on excitable tissues
hyperpolarizes
36
How does renal insufficiency affect mag infusion
Kidneys eliminate Mg2+
37
What clinical assessment is used to determine the presence of hypermagnesemia
Deep tendon reflexes | If they are present, more serious side effects are low
38
What assessment can be a first sign of mag toxicity
Diminished DTRs
39
At what magnesium level are tetany, seizures and dysrhythmias possible
Mg < 1.2 mg/dL
40
At what magnesium level are diminished DTRs, lethargy, drowsiness, and flushing present
5--7 mg/dL
41
At what magnesium level are DTRs absent, HoTN, EKG changes, and somnolence present
7-12 mg/dL
42
At what magnesium level are CHB, respiratory depression, cardiac arrest, and coma possible
>12 mg/dL
43
What effect does magnesium infusion have on NMB
It can potentiate NMB especially if hypermagnesemia is present
44
What pulmonary complications are possible with hypermagnesemia
Pulmonary edema
45
How do pts with hypermagnesemia respond to ephedrine or phenylephrine
They have a reduced response
46
What are 3 treatments for hypermagnesemia
1. supportive measures 2. diuretics to facilitate excretion 3. IV calcium gluconate 1g to antagonize Mg2+
47
How do CCB act as a tocolytic
They block the influx of Ca++ into the uterine muscle, reducing Ca++ release from SR, turning off myosin light-chain kinases. Ultimately relaxes uterine muscle
48
What is the first-line CCB used as a tocolytic
nifedipine
49
Define premature delivery
delivery before 37 weeks or less than 259 days from LMP
50
The incidence of prematurity increases with what 2 factors
1. multiple gestations | 2. PROM
51
Coadministration of nifedipine with what drug increases the likelihood of skeletal muscle weakness in the pregnant patient
Magnesium
52
3 Medications used as uterotonics
1. oxytocin 2. methergine (ergot alkaloid) 3. prostaglandin F2 (hemabate or carboprost)
53
Where is oxytocin synthesized and store/released
``` synthesis = the paraventricular nuclei of hypothalamus store/released = posterior pituitary gland ```
54
Stimulation of what 3 areas can release endogenous oxytocin
1. Cervix 2. vagina 3. breasts
55
What hormone is pitocin equivalent to
It is a synthetic equivalent of oxytocin
56
What are 3 indications for oxytocin
1. induction or augmentation of labor 2. stimulating uterine contraction 3. combating uterine hypotonia and hemorrhage
57
Why is oxytocin used during C/S
uterine contraction following placental delivery
58
What are 5 side effects of oxytocin
1. Water retention 2. hyponatremia 3. HoTN 4. reflex tachycardia 5. coronary vasoconstriction
59
What is a consequence of rapid oxytocin IV administration
CV collapse
60
How is oxytocin metabolized
hepatic metabolism
61
What is the half-life of oxytocin
4-17 minutes
62
What type of medication is methergine
Ergot alkaloid
63
What are the second-line and third-line uterotonics
``` 2nd = methergine 3rd = hemabate ```
64
What is the dose of methergine
0.2 mg IM
65
What are the consequences of methergine IV administration
1. significant vasoconstriction 2. HTN 3. Cerebral hemorrhage
66
How is methergine metabolized and the half-life
``` metabolism = hepatic half-life = 2 hrs ```
67
What type of medication is hemabate
prostaglandin F2
68
What is the dosing for hemabate
250 mcg IM
69
What are 5 side effects of hemabate/carboprost
1. N/V 2. Diarrhea 3. HoTN 4. HTN 5. bronchospasm
70
At what point during a c-section should oxytocin be used
after delivery of the placenta
71
What are 5 situations that general anesthesia should be used for CS
1. Maternal hemorrhage 2. Fetal distress 3. Coagulopathy 4. Pt refusal of RA 5. Contraindications to RA
72
How does general anesthesia affect maternal mortality
It is 17-times higher in this population
73
What is the most common cause of maternal death associated with GA
failure to successfully manage the airway
74
What are 3 prophylactic medications used in the maternal population undergoing GA for CS
1. sodium citrate 2. H2 receptor antagonist (ranitidine) 3. Gastrokinetic agent (reglan)
75
Why is neonatal depression not a concern with GA induction drugs
Depression is short-lived b/c of redistribution
76
What are 11 steps for a GA C/S
1. Plan for difficult intubation. 2. Triple aspiration prophylaxis 3. LUD 4. Place monitors 5. Surgical prep and drape 6. Preoxy while prepping 7. Induction 8. Once ETT passes through cords yell "CUT" 9. Use MAC<0.5 + nitrous to prevent uterine atony 10. Give oxytocin once placenta delivered (BZDs for amnesia) 11. Extubate when fully awake
77
How much amniotic fluid may be present in the EBL suction
~700 mL
78
What are 3 benefits of GA for C/S
1. Speed of onset 2. Secure airway 3. Greater hemodynamic stability
79
What type of non-obstetric surgeries have the greatest risk of preterm labor
abdominal and pelvic procedures
80
What are fetal risks associated with non-obstetric procedures
1. growth restriction 2. low birth weight 3. fetal demise 4. increased incidence of preterm labor
81
What are 2 maternal risks associated with non-obstetric surgeries
1. Difficult intubation | 2. Risk of aspiration
82
When is the best option for timing of surgical procedures in the parturient and why
2nd trimester | It avoids high risk of teratogenicity during 1st trimester and increased risk of preterm delivery during 3rd trimester
83
Why should N2O be avoided in the first 2 trimesters
It may be linked with congenital disabilities due to DNA synthesis inhibition
84
At what point during the pregnancy are pts considered full stomach How does this affect the anesthetic
18-20 weeks | RSI with aspiration prophylaxis
85
How much sodium citrate should be given to a parturient and when should it be given before a procedure
``` Dose = 15-30 mL timing = 15-30 min before induction ```
86
What 4 physiologic abnormalities should be avoided in the parturient during non-obstetric procedures Why
1. Hypoxemia 2. Hyperventilation 3. HoTN 4. Acidosis These states can reduce placental BF
87
Why are NSAIDs avoided during pregnancy
To prevent closure of the ductus arteriosus
88
How does gestational HTN differ from pre-eclampsia and chronic HTN
It is HTN that presents after 20 weeks w/o proteinuria. BP returns to normal after delivery
89
How does preeclampsia differ from gestational HTN
PreE presents with proteinuria
90
What are BP parameters for Pre-E
``` mild = >140/90 severe = >160/110 ``` develops after 20 weeks
91
What are 5 other conditions that can be considered part of pre-E
1. persistent RUQ or epigastric pain 2. Persistent CNS or visual symptoms (i.e. HA) 3. Fetal growth restriction 4. Thrombocytopenia 5. Elevated liver enzymes
92
What is eclampsia
When a mother with pre-E develops seizures
93
What maternal age-ranges are at greater risk for pre-E
<20 yrs and >35 yrs
94
What 2 pt population are at highest risk for pre-E
1. Chronic renal disease | 2. Homozygous for angiotensinogen T235 allele
95
What 2 products of arachidonic acid are produced by the placenta
1. Thromboxane | 2. Prostacyclin
96
How are thromboxane and prostacyclin affected by pre-E
They produce 7 times more thromboxane than prostacyclin
97
What 3 actions does elevated thromboxane have in the pre-E pt
1. Favors vasoconstriction 2. Favors plt aggregation 3. Reduces placental BF
98
What additional mediators may be released from the diseased placenta in pre-E The effects
Cytokines | Promote endothelial dysfunction
99
What are 4 purposes of prostacyclin release from the placenta
1. dec plt aggregation 2. dec vasoconstriction 3. dec uterine activity 4. increased uteroplacental BF
100
What are key complications of pre-E on maternal physiology
1. HF 2. Pulmonary edema 3. Intracranial hemorrhage 4. cerebral edema 5. DIC 6. proteinuria
101
What are 3 vasoactive substances that are released from placental ischemia
1. Cytokines 2. Radicals 3. Peroxides
102
Why does proteinuria occur with pre-E
There is glomerular leak d/t endothelial damage from thromboxane and vasoactive substances
103
Why is BP elevated during pre-E
d/t increased thromboxane causing vasoconstriction
104
What causes generalized or pulmonary edema in the pre-E pt
Decreased oncotic pressures | Increased vascular permeability d/t endothelial damage
105
What causes HA and visual impairment with severe pre-E
HA = cerebral edema | Visual changes = vasoconstriction of ocular arterioles
106
What can cause epigastric pain in the severely pre-E pt
Liver subcapsular hemorrhage or hypoxic liver
107
Why does plt count drop in the pt w/ severe pre-E
d/t consumption by endothelial damage
108
What is the definitive treatment for pre-E and eclampsia
Delivery of the fetus and placenta
109
When is delivery mandatory in the pre-E pt
when fetal distress occurs or maternal symptoms are severe
110
What is the reason to medicate BP > 160/110
To prevent 1. CVA 2. MI 3. Placental abruption
111
Wat are 4 treatments for acute maternal HTN
1. labetalol 20 mg, max 220 mg 2. hydralazine 5 mg, max 20 mg 3. Nifedipine 10 mg PO, max 50 mg 4. Nicardipine infusion
112
Once the neonate is delivered, when does pre-E resolve
It can be up to 4 weeks postpartum before pre-E resolves | It can still occur after delivery
113
What are the benefits of neuraxial anesthesia with pre-E | What is ruled out prior to performing
It assists with BP control and provides better uteroplacental perfusion r/o thrombocytopenia (plt <100,000)
114
In pre-E pts, what medication can affect NMB during GA
Many pts are on Mg drips. This increases the sensitivity to neuromuscular blockers
115
What differentiates pre-E from eclampsia
Seizures are present w/ eclampsia
116
How are seizures prevented in the pre-E pt
Prophylaxis w/ mag sulfate
117
What is the dosing for seizure prophylaxis with magnesium sulfate
``` load = 4 g over 10 min infusion = 1-2 g/hr ```
118
What is the treatment for Mg++ toxicity
10 mL 10% Ca++ gluconate IV (Mg antagonist)
119
What is HELLP
Hemolysis Elevated Liver enzymes Low Platelet count
120
What is the incidence of HELLP in the pre-E pt
5-10%
121
Treatment for HELLP
delivery of fetus and placenta
122
What 2 complications are pts with HELLP at high risk for
1. DIC | 2. Intra-abdominal bleeding form liver
123
What is the MOA of cocaine
inhibition of NE reuptake in presynaptic SNS | Increased NE = increased SNS tone
124
What are 4 CV risks with cocaine abuse
1. tachycardia 2. dysrhythmias 3. coronary vasoconstriction 4. myocardial ischemia
125
How does cocaine affect MAC
``` Acute = increases MAC Chronic = decreases MAC ```
126
What are 4 CNS risks with cocaine abuse
1. cerebral vasoconstriction 2. Ischemia 3. Seizures 4. Stroke
127
What are 4 OB risks with cocaine use
1. spontaneous abortion 2. premature labor 3. placental abruption 4. low APGAR scores
128
What anti-HTN medication should be used in the cocaine intoxicated parturient and why
labetalol | It blocks alpha-mediated peripheral vasoconstrictoin
129
What anti-HTN medication should be avoided in the cocaine intoxicated parturient and why
Beta-blockers B1 causes myocardial depression that can lead to heart failure if SVR is elevated B2 leads to impaired vasodilation of muscular beds causing heart failure and a further increase in elevated SVR
130
Why is ephedrine not appropriate to use in chronic cocaine abusers
Catecholamines are depleted Phenylephrine is the best option
131
What hematologic disorder is chronic cocaine use associated with Significance in parturient
Thrombocytopenia Check plt level before neuraxial
132
What are 4 roles of thromboxane in the pre-E pt
1. inc plt aggregation 2. inc vasoconstriction 3. inc uterine activity 4. dec uteroplacental BF
133
What are the 3 types of abnormal placental implantations from least to most severe
``` Accreta = attaches to surface of myometrium Increta = invades myometrium Percreta = extends beyond the uterus ```
134
How is a normal placenta implanted in the uterus
It's implanted into the decidua of the ENDOmetrium
135
Define placenta previa
Placenta attaches to the lower uterine segment and either partially or completely covers the cervical os
136
What type of bleeding is associated with placenta previa
painless vaginal bleeding with potential for hemorrhage
137
What are 2 risk factors for placental previa
1. previous c/s | 2. history of multiple births
138
Define placental abruption
Partial or complete separation of the placenta from the uterine wall before delivery
139
What are 6 risk factors for placental abruption
1. PIH 2. Pre-E 3. chronic HTN 4. Cocaine use 5. smoking 6. excessive etoh use
140
What are associated maternal symptoms of placental abruption
pain and vaginal hemorrhage
141
What other maternal complication is associated with placental abruption
amniotic fluid embolism leading to DIC
142
What is the most common cause of postpartum hemorrhage
Uterine atony
143
What are 4 factors that increase the risk of uterine atony
1. multiparity 2. multiple gestations 3. Polyhydramnios 4. prolonged oxytocin before surgery
144
What are 7 other causes of obstetric bleeding besides uterine atony
1. retained placenta 2. laceration of cervix 3. uterine inversion 4. coagulopathy 5. placenta previa 6. placental abruption 7. abnormal placental implantation
145
What medication can be given for retained placenta and why
IV nitroglycerin provides uterine relaxation for placental extraction
146
What 3 conditions are maternal DIC associated with
1. AFE 2. Placental abruption 3. Intrauterine fetal demise
147
When are Apgar scores calculated
At 1 and 5 minutes after delivery
148
What do the Apgar scoring times correlate with what fetal conditions
1 min = fetal acid-base status | 5 min = predictive of neurologic outcomes
149
What are the following Apgar scores: Normal = Moderate distress = Impending demise =
Normal = 8-10 Moderate distress = 4-7 Impending demise = 0-3
150
What are the 5 measures of Apgar scoring
1. HR 2. Respiratory effort 3. Muscle tone 4. Reflex irritability 5. Color
151
What a normal neonatal HR and RR
``` HR = 120-160 RR = 30-60 ```
152
Why should supplemental O2 be avoided in the neonate
It increases risk of an inflammatory response
153
What is the dose for | PRBCs, NS, and LR volume expanders in the newly delivered neonate
10 mL/kg

APEX-across the lifespan (7 decks)

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