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Advanced Principles A (Spring 2024) > Maternal Physiology (Exam II) > Flashcards

Maternal Physiology (Exam II) Flashcards

1
Q

Gravida refers to what?

A

Number of pregnancies (not babies)

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2
Q

Para refers to what?

A

numbers of births (>20weeks)

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3
Q

What is G0P0?

A

Nulligravida/Nulliparous

  • No pregnancies
  • No births
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4
Q

What would G3P2 refer to?

A

Multigravida/ Multiparous

  • 3 pregnancies
  • 2 births
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5
Q

How long is a pregnancy? When is a gestation “term”?

A
  • 40 weeks
  • Term at 37 - 40 weeks
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6
Q

What are the components that result in the 12kg weight gain typical of pregnancies?

A
  • Uterus & Amniotic Fluid = 1kg
  • Fetal/Placental Weight = 4kg
  • New Fat/Protein stores = 4kg
  • Blood volume increase = 2kg

lol this is 11kg…

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7
Q

Do women of all BMI’s gain weight the same during pregnancies?

A

No

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8
Q

How much does total blood volume increase during pregnancy?

A

30 - 35% increase

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9
Q

When does the increase in total blood volume of the typical pregnant woman occur?

A

8 - 32 weeks (Majority by 24 weeks)

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10
Q

Does plasma volume or RBC volume increase more during pregnancy?

A

Both increase but plasma volume increases more.

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11
Q

Why does blood volume increase during pregnancy?

A

To counteract delivery blood loss

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12
Q

Approximately when does maternal blood volume return to normal post-delivery?

A

6 weeks

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13
Q

Compare the blood volume of a pregnant patient and a non-pregnant patient in mL/kg.

A

Non = 65mL/kg
Pregnant= 85-90 mL/kg

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14
Q

CO will increase by ___% by term.

A

40%

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15
Q

In regards to hemodynamics, by 6 weeks there will be an increase in maternal _____ ____ and by 8 - 10 weeks there will be an increase in _____ _____.

A

Heart Rate : Stroke Volume

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16
Q

What is the mechanism for increased Stroke Volume in the pregnant patient?

A

↑ Plasma Renin = ↑aldosterone = ↑ Preload = ↑ SV

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17
Q

How much does uterine blood flow increase during pregancy?

A

Baseline = 50 mL/min
Term = 700 mL/min

20x increase!

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18
Q

What is the cause of the pregnancy symptoms of warm skin, flushing, and itching?

A

3-4x increase in skin blood flow

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19
Q

What changes in SVR occur in pregnancy?

A

20% lower

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20
Q

What hormones are responsible for maternal vasodilation?

A
  • Progesterone
  • Prostacyclin
  • Relaxin
  • Estrogen
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21
Q

Pregnancy is a ____ flow, _____ resistance state.

A

High flow : low resistance

↑ CO and ↓ SVR

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22
Q

Do the following increase or decrease during pregnancy?

  • Blood volume
  • Cardiac Output
  • SVR
  • Heart rate
A
  • ↑ Blood volume
  • ↑ Cardiac Output
  • ↓ SVR
  • ↑ Heart rate
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23
Q

What changes are seen in a maternal heart due to pregnancy?

A

Eccentric Hypertrophy (as much as 50%)

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24
Q

How does the heart shift due to pregnancy?
Why does this occur?

A
  • Heart shifts anterior and leftward due to diaphragmatic elevation.
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25
Q

Where does the point of maximal impulse for auscultation shift in a pregnant patient?

A

4th ICS mid-clavicular line

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26
Q

What EKG changes are seen in a pregnant patient?

A
  • Left Axis shift in 3rd trimester
  • Lead III T-wave inversion
  • PR interval shortened
  • ST segment depressed
  • QT interval increased
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27
Q

What are the most common EKG abnormalities in pregnant patients?

A

Tachydysrhythmias

(Sinus tach, PAC, PVC)

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28
Q

What valvular changes are typical of pregnancy?

A
  • Tricuspid & Pulmonic regurgitation (>90% pts)
  • Mitral regurgitation (~25% of pts)

These typically reverse postpartum.

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29
Q

What heart sound is often heard in the 3rd trimester?
What causes this?

A

Ventricular Gallop

Due to inrush of large blood volume into very compliant left ventricle.

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30
Q

What heart sound disappears at term?

A

4th heart sound

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31
Q

What murmur can occur due to cardiac enlargement?
Where is this best heard?

A
  • Grade II SEM (systolic ejection murmur)
  • Heard right side of heart, near sternal border
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32
Q

What occurs in the supine position of a pregnant woman?

A

Aortocaval compression

Uterus compresses great vessels.

Occurs as early as 13-16 weeks.

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33
Q

What exacerbates aortocaval compression?

A

Anesthesia due to vasodilation.

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34
Q

What are the s/s of aortocaval compression?

A
  • Fetal Distress
  • Tachycardia → bradycardia
  • N/V
  • Pallor
  • Syncope
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35
Q

What is the treatment for aortocaval compression?

A

LUD (Left Uterine Displacement)

Done by tilting the patient to the left.

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36
Q

What cardiovascular changes occur during the first stage of labor?

A
  • CO increases before & during contractions
  • HR increases
  • Autotransfusion of 300-500mls from uterus to general circulation w/ each contraction.
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37
Q

What cardiovascular changes occur during the second stage of labor?

A

CO increases by 50% due to:

  • Pushing effort
  • ↑ SV & HR
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38
Q

What cardiovascular changes occur during the second stage of labor?

A

CO increases by 60 - 80% due to

  • Relief from vena cava obstruction
  • Uterine contracts blood into circulation
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39
Q

When does CO return to normal post-delivery?

A

24 hours

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40
Q

What happens to the airway in obstetric patients?

A
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41
Q

What are the anesthetic implications of edematous airways?

A
  • Smaller ETT necessary
  • Avoid NGT/Nasal trumpets (bloody nose)
  • Airway obstruction risk increases
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42
Q

How does the hormone estrogen effect the obstetric patient’s pulmonary system?

A

Estrogen will ↑ number and sensitivity of progesterone receptors in the respiratory center of the brain.

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43
Q

How does the hormone Progesterone effect the obstetric patient’s pulmonary system?

A
  • ↑ respiratory center sensitivity to CO₂
  • Bronchodilates
  • Causes edematous airways
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44
Q

How does the hormone Relaxin effect the obstetric patient’s pulmonary system?

A

Causes ligamentous attachments to lower ribs to relax.

  • subcostal angle increases
  • widened AP & transverse diameter of chest wall.
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45
Q

Is Total Lung Capacity reduced or preserved during pregnancy?

A

Preserved.

Chest height is shortened but A-P dimension increases with barrel shape due to relaxin.

46
Q

What is FRC?

A

Volume of air that prevents complete emptying of lungs and keeps small airways open.

47
Q

What is ERV?

A

Volume of air that can be expired with maximum effort at the end of normal expiration.

48
Q

What is RV?

A

Residual Volume = Volume of air in the lungs after ERV is expired

49
Q

Uterine elevation of the diaphragm results in a _____% decrease in FRC.

A

20% ↓ in FRC (Both ERV and RV are decreased).

50
Q

What causes the earlier closure of small airways in the obstetric patient?

A

Elevated Diaphragm → more negative pleural pressure = small airway closure

51
Q

What position results in a more profound decrease in FRC?

A

Supine

52
Q

What happens if closing capacity exceeds FRC?

A

Small airway closure & V/Q mismatch leading to
O₂ desaturation.

53
Q

What respiratory volumes are increased during pregnancy?

A
  • VT ( increased CO₂ production = increased respiratory drive)
  • IC (Inspiratory Capacity)
54
Q

What respiratory volumes are unchanged by pregnancy?

A
  • TLC (all lung volumes)
  • VC (IC + VT + ERV)
55
Q

How can pre-oxygenation be achieved?

A
  • 3 - 5 VC breathes with tight face mask w/ 100% O₂
  • 8 deep breaths at O₂ flow rate 10L/min over 1 min.
56
Q

What FeO₂ (fraction of expired O₂) is desirable?

A

0.9 or greater

57
Q

What positioning is helpful for preoxygenation?

A

20° Reverse Trendelenburg

58
Q

How much does O₂ consumption increase by at term?

A

20%

Due to increased metabolism of mom & baby, increased work of breathing, and increased cardiac workload.

59
Q

How do minute ventilation and alveolar ventilation change in pregnancy?

A

Both Increase.

RR increases by 1-2 breaths per minute, mediated by hormonal changes.

60
Q

How do ABG’s change during pregnancy?
What does this result in?

A

PaCO₂ decreases by 8-10 mmHg
PaO₂ increases by 5 mmHg

Respiratory Alkalosis is normal in healthy pregnancies.

61
Q

Compare and contrast a typical ABG vs an obstetric ABG.

A
62
Q

What pulmonary change occurs during the first stage of labor?

A

Minute ventilation increases by up to 140%.

63
Q

What pulmonary change(s) occurs during the second stage of labor?

A
  • V̇T goes up by 200%
  • Maternal CO₂ decreases by 10 - 15
  • O₂ consumption increases
  • Maternal lactate increases

Supplemental O₂ might be necessary.

64
Q

What hematologic changes occur during pregnancy?

A
  • Plasma volume increases more than RBC mass resulting in dilutional anemia.
  • Hgb drops by 2.5 g/dL
  • HCT decreases by 6.5%
65
Q

What Hgb range do we like for maternal patients?

A

11 - 13 g/dL

  • Less than 11 is abnormal
  • > 13 means you need to watch for pre-eclampsia.
66
Q

What changes occur with platelets during pregnancy?

A
  • Normal 165 - 415
  • No change or moderate decrease is typically seen with pregnancy.
67
Q

Why do we care about platelets in obstetric patients?

A

Risk for epidural hematoma from neuraxial techniques.

68
Q

Pregnancy produces a hypercoagulable or hypocoagulable state?

A

Hypercoagulable.

69
Q

What coagulation factors increase due to pregnancy?

A

All of them, except II, V, XI, and XIII.

70
Q

What coagulation factor has the most significant increase during pregnancy?

A

Factor 1 (Fibrinogen)

71
Q

What is hyperfibrinogenemia?

A

Fibrinogen (Factor I) > 400mg/dL at term

  • Increased clotting efficiency
  • Impaired fibrinolysis
72
Q

What factors are increased at term gestation?

Will be on test

A
  • I (Fibrinogen)
  • VII (proconvertin)
  • VIII (Antihemophilic factor)
  • IX (Christmas factor)
  • X (Stuart-Prower factor)
  • XII (Hageman factor)
73
Q

What factors are unchanged at term gestation?

Will be on test

A
  • II (Prothrombin)
  • V (Proaccelerin)
74
Q

What factors are decreased at term gestation?

Will be on test

A
  • XI (Thromboplastin antecedent)
  • XIII (Fibrin-stabilizing factor)
  • PT & PTT ↓ by 20%
  • Fibrinolytic activity overall decreases in 3rd trimester
75
Q

What occurs with WBC’s during pregnancy?

A
  • Increase steadily to 9 - 10 throughout pregnancy
  • Spike up to 34 during labor
76
Q

How does immune function change during pregnancy?

A
  • Leukocyte function is impaired
  • Antibody titers can decrease
77
Q

All parturient patients are considered to be _____ stomach.

A

full

78
Q

How does lower esophageal sphincter tone change throughout pregnancy?

A
  • Tone decreases throughout pregnancy with the lowest tone occurring at term.
  • LES tone normalizes at 4 weeks post-partum.
79
Q

What is Mendelson’s Syndrome?

A

Aspiration pneumonitis & inflammatory response of lung parenchyma

80
Q

What puts one at greater risk of Mendelson’s syndrome?

A
  • pH < 2.5
  • > 25mL gastric volume
81
Q

Uterus takes ____ weeks to return to normal size.

A

6

82
Q

What changes occur in the liver during pregnancy?

A

↑ risk of esophageal varices due to increased portal vein pressure.

↑ Liver enzymes and cholesterol

83
Q

What occurs with serum albumin during pregnancy?

A

serum albumin decreases

84
Q

What occurs with pseudocholinesterase levels during pregnancy?

A

pseudocholinesterase decreases by 25 - 33% during the peri-delivery timeframe.

*Usually still okay to give Sux**.

85
Q

When can cholestasis occur to parturient patients?

A

3rd trimester

86
Q

What are the s/s of cholestasis?

A
  • Pruritis
  • ↑ bilirubin
  • ↑ LFTs
87
Q

What are the consequences of cholestasis in obstetric patients?

A
  • ↑ risk of cholelithiasis
  • ↑ risk of cholecystectomy
  • ↑ risk of cholestasis in subsequent pregnancies
88
Q

During pregnancy the kidneys see a _____ increase in renal blood flow.

A

75%

89
Q

What are the results of increased renal blood flow during pregnancy?

A
  • ↑ GFR
  • ↑ Creatinine clearance
  • ↓ Creatinine
  • ↓ BUN
90
Q

What BUN/Creatinine levels are typical of pregnant patients?

A
  • BUN: 8 - 9 mg/dL at term
  • Ct: 0.5 - 0.6 mg/dL at term
91
Q

What changes in the urine can occur during pregnancy?

A
  • Glycosuria common (Glucose reabsorption can’t keep up with ↑ GFR)
  • Proteinuria
92
Q

What would a finding of proteinuria possibly indicate in a parturient patient?

A

preeclampsia

93
Q

What would the following labs in a parturient patient suggest?

  • BUN > 15mg/dL
  • Creatinine > 1.0 mg/dL
  • Creatinine Clearance < 100 mL/min
A

Abnormal renal function

Further evaluation required.

94
Q

What occurs with the thyroid during pregnancy?

A

Enlargement by 50 - 70%

Hypothyroidism may occur and require levothyroxine to prevent fetal issues.

95
Q

Insulin resistance during pregnancy is the result of what hormone?

A

Human placental lactogen

Hormone that prepares the body for breastfeeding.

96
Q

How does adrenal function change in the parturient patient?

A
  • ↑ cortisol (200% by term)
  • ↑ plasma endorphins
97
Q

How does the anterior pituitary change during pregnancy?

A
  • 300% increase in size
  • ↑ Prolactin secretion
98
Q

What causes increased acne seen in pregnancy?

A

↑ Prolactin secretion by adenophypophysis hyperplasia.

99
Q

How does the posterior pituitary change during pregnancy?

A

Oxytocin secretion increases by 30% by term

  • Stimulates contractions
  • Breast milk letdown
  • “Bonding hormone”
100
Q

What hormone is responsible for breast milk letdown and is known as the “bonding” hormone?

A

Oxytocin

101
Q

What nerve pains are common with pregnancy?

A
  • Sciatic
  • Meralgia paresthetica
102
Q

What is meralgia paresthetica?

A
  • Compression of lateral femoral cutaneous nerve at exit site of pelvis)

Tingling, numbness, and burning on lateral aspect of the thigh.

103
Q

What is the reason for lots of pelvic pain during pregnancy?

A

Lumbar lordosis w/ anterior pelvic tilt and narrowing of intervertebral spaces.

104
Q

What CNS changes occur during pregnancy?

A
  • ↑ CBF
  • ↑ BBB permeability
  • ↑ pain threshold
105
Q

What is the mechanism for increased pain threshold for parturient patients?

A
  • Progesterone activates κ-opioid receptors
  • ↑ plasma endorphins
106
Q

What occurs with the epidural space in pregnant women?

A
  • ↑ Venous plexus volume
  • ↓ CSF volume
107
Q

What is the result of increased venous plexus volume?

A

Engorged epidural veins and a higher risk of venous puncture during epidural placement.

108
Q

What is the result of decreased CSF volume on local anesthetic spread?

A

↑ spread of LA

109
Q

T/F. A higher total dose of local anesthetic is necessary to produce the same level of neuraxial block in parturient patients.

A

False. A lower total dose of LA is necessary.

110
Q

Parturient patients have an increased sensitivity to _______ neuromuscular blockers.

A

Non-depolarizing.

Roc & Vec

111
Q

What can happen with succinylcholine administration in a pregnant patient?

A

Prolonged paralysis due to ↓ pseudocholinesterase activity.

112
Q
A

Advanced Principles A (Spring 2024) (11 decks)

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