OB Flashcards
(360 cards)
1
Q
anes for OB
A
PP
2
Q
TERM PREGNANCY: Greater than how many weeks? PRE-TERM LABOR: Labor between what weeks of pregnancy?
A
37;
the 20th and 37th week
3
Q
what type of meds are commonly used to treat pre-term labor? how do they work? name 3 examples.
A
TOCOLYTIC MEDICATIONS;
Relaxation of smooth muscle;
Magnesium sulfate, indomethacin, and Nifedipine
4
Q
CV changes with pregnancy: Increased blood volume by about what% to meet increased fetal/ maternal demands (e.g. blood loss during delivery)
A
45%
5
Q
CV changes with pregnancy: Increased cardiac output about 40% related to what 2 things?
A
increased SV and HR (Up to 20-50% increase for both)
6
Q
CV changes with pregnancy: Systemic vascular resistance (SVR) decrease what% due to decrease in overall vascular tone
A
10 – 15%
7
Q
CV changes with pregnancy: does the size of the heart change with all the hemodynamic changes? at what point in the pregnancy is this seen?
A
yes, hypertrophy;
1st and 2nd trimester
8
Q
CV changes with pregnancy: why does cardiac output (CO) and blood volume (BV) increase?
A
to meet accelerated maternal and fetal metabolic demands
9
Q
CV changes with pregnancy: what causes the dilutional anemia and reduces blood viscosity? how does hgb values change?
A
An increase in plasma volume in excess of an increase in red cell mass;
Hemoglobin (Hgb) concentration usually remains >11 g/dL.
10
Q
CV changes with pregnancy: The reduction in Hgb concentration is offset by what?
A
the increase in CO and the rightward shift of the Hgb dissociation curve
11
Q
CV changes with pregnancy: what hemodynamic parameter decreases in the 2nd trimester that decreases both diastolic and SBP.
A
A decrease in SVR by the 2nd trimester decreases both diastolic and SBP.
12
Q
CV changes with pregnancy: At term, BV is increased by how much mL, allowing them to easily tolerate the blood loss associated with delivery? Total BV reaches how much mL/kg? when does BL return to normal?
A
1000-1500mL;
90 mL/kg00mL;
1-2 weeks after delivery
13
Q
CV changes with pregnancy: *Greatest increases in CO are seen during what events? when does CO returns to normal?
A
during labor and immediately after delivery;
CO returns to normal 2 weeks after delivery
14
Q
CV changes with pregnancy: all pregnancies are considered what ASA?
A
II
15
Q
CV changes with pregnancy: Changes begins as early as what week of pregnancy.
A
4th
16
Q
CV changes with pregnancy: HR increased by what% at term?
A
20-30%
17
Q
CV changes with pregnancy: HR increase begins in what trimester and peaks at how many weeks of gestation.
A
1st trimester;
32 weeks
18
Q
CV changes with pregnancy: At term, what% of CO perfuses the gravid uterus
A
10%
19
Q
CV changes with pregnancy: When in labor, CO increases during uterine contractions due to what?
A
autotransfusion from the contracting uterus to the central circulation
20
Q
CV changes with pregnancy: Immediately after delivery, CO increases as much as how much% above predator values? why?
A
80%;
due to increase in central volume from the contracted uterus and relief of aortocaval compression
21
Q
CV changes with pregnancy: The diaphragm rises during pregnancy, shifting the heart in which direction, making the cardiac silhouette appear enlarged on x-ray
A
to the left
22
Q
CV changes with pregnancy: The ventricular walls thicken and end-diastolic volume decr/incr?
A
incr
23
Q
CV changes with pregnancy: is it usual to hear a grade 1 or 2 systolic murmur or a 3rd heart sound? when a systolic murmur is > than grade what or accompanied by chest pain or syncope, further evaluation is needed?
A
yes;
grade 3
24
Q
CV changes with pregnancy: are Diastolic and cardiac enlargement are considered pathologic?
A
yes
25
CV changes with pregnancy: Total blood volume increases by what% throughout pregnancy
25-40%
26
CV changes with pregnancy: Plasma volume increases by what% whereas RBCs volume increase by only what%?
40-50%;
| 20%
27
CV changes with pregnancy: The incr in plasma volume is likely the result of greater circulating levels of what 2 hormones resulting in enhanced renin-angiotensin-aldosterone activity
progesterone and estrogen
28
CV changes with pregnancy: Average vaginal EBL is how much mL? and uncomplicated c-section EBL is how much mL.
500 mL;
| 800-1000 mL
29
CV changes with pregnancy: In labor each contraction moves how much mL of blood from the contracting uterus to the central circulation
300-500ml
30
CV changes with pregnancy: In the presence of adequate what and little sympathetic stimulation, there’s often a corresponding decr in maternal HR during uterine contractions due to what?
neuraxial analgesia;
| transiently incr preload
31
CV changes with pregnancy: what CV change by end of term pregnancy, owe to a large decr resistance in the uteroplacental, pulmonary, renal, and cutaneous vascular beds
SVR decr as much as 21% by end of term pregnancy
32
CV changes with pregnancy: The decr in SVR effect the SBP during normal pregnancy?
no, despite the incr blood volume
33
CV changes with pregnancy: A decr in DBP of up to how much mm Hg may occur, resulting in a decr in what pressure?
15 mm Hg;
| mean pressure
34
CV changes with pregnancy: The gravid uterine blood flow is how many X above nonpregnant level, accounting for 20% of maternal CO at term
20-40x
35
CV changes with pregnancy: what causes the aortocaval compression or the “maternal supine hypotensive syndrome.”
The enlarged uterus produces mechanical compression of surrounding vascular structures
36
CV changes with pregnancy: In the supine position, compression of the inferior vena cava decreases venous return, resulting in what 3 CV effects? Compression of the aorta further decreases uterine perfusion and may result in what?
decreased SV/CO and hypotension;
| fetal distress
37
CV changes with pregnancy: Normal maternal compensatory responses to aortocaval compression consist of what 2?
tachycardia and lower-extremity vasoconstriction
38
Resp changes: Changes evident after how many weeks gestation
12
39
Resp changes: The expanding uterus produces cephalad displacement of the diaphragm resulting in a decr in what 2 resp parameters? which plays a major role in preserving O2 saturation during hypoventilation or apnea
FRC, expiratory reserve (ER), and residual volume (RV);
| FRC
40
Resp changes: The decr FRC combined with the increase in what commonly results in rapid arterial desaturation in the apneic pregnant patient. Morbid obesity, labor and sepsis exaggerate this effect.
O2 consumption
41
Resp changes: how do Total lung capacity (TLC), vital capacity (VC), and Inspiratory capacity (IC) change?
= unchanged due to compensatory subcostal widening and enlarging of the thoracic anteroposterior diameter.
42
Resp changes: Term pregnancy = incr 02 consumption up to what% at rest? and what% during the 2nd stage of labor due to increase in alveolar ventilation at term?
33%;
| 100%
43
Resp changes: Elevation of the diaphragm seen in what trimester? Results in about a what% decrease in FRC that mimics what type of lung disease?
third;
20% decrease in FRC;
mimics restrictive lung disease
44
Resp changes: Increased oxygen demand coupled with decreased reserve results in…. ?
rapid desaturation
45
Resp changes: what causes maternal arterial pressure of CO2 to drop below 15 mmHg
During labor, increases of minute ventilation of up to 300% can occur in response to pain
46
Resp changes, airway: Generalized airway edema from what?
capillary engorgement
47
Resp changes, airway: Overall narrowing of glottic opening can result from what? The possibility of technically difficult intubation requiring what should be kept in mind when caring for these patients
edema;
| small-diameter ETT (7 or 6.5)
48
Resp changes, airway: Nasal intubation of the parturient should generally be avoided?
true
49
Metabolic change: incidence of gestational DM? what are the 2 complications to the fetus due to this?
3%;
| decr placental perfusion and impaired O2 transport
50
Metabolic change: what are the 2 diagnostic tests for gestational DM?
glycosuria and glucose challenge/tolerance test
51
Metabolic change: when is a glucose challenge/tolerance test typically performed (at what week) if no h/o of it? when if there is a h/o gest. DM?
24-28 weeks;
| 13 weeks
52
Metabolic change: gestational DM increases the change of what procedure?
c-section due to high birth wts
53
Metabolic change: gestational DM can decrease uteroplacental circulation by what %
35 – 45%
54
Metabolic change, gestational DM: what causes the infant hypoclymia? Must check what lab at delivery of infant?
Increase glucose in mother;
| infant’s blood sugar is checked.
55
Metabolic change: Altered carbohydrate, fat, and protein metabolism favors fetal what? These changes resembles starvation why?
growth and development;
because blood glucose and amino acids levels are low, whereas free fatty acids, ketones, and triglyceride levels are high
56
Metabolic change: Pregnancy is a diabetogenic state why? Insulin levels steadily rise during pregnancy. Secretion of what by the placenta is probably responsible for the relative insulin resistance associated with pregnancy.
Insulin levels steadily rise during pregnancy;
| Secretion of human placental lactogen, also called human chorionic somatomammotropin
57
Metabolic changes: Pancreatic beta cell hyperplasia occurs in response to an increased demand for what?
insulin secretion
58
Metabolic changes: Secretion of human chorionic gonadotropin and elevated levels of estrogens promote hypertrophy of what gland? resulting in increase what hormone?
thyroid gland;
| thyroid-binding globulin.
59
Metabolic changes: how are T3 and T4 and free T3 and T4 and thyrotropin effected?
T3 and T4 are elevated but free T3 and T4 and thyrotropin are normal
60
Renal changes: Kidneys increase in size and weight during pregnancy and return to normal size when?
6 months post partum
61
Renal changes: when do renal pelvis and ureters begin to dilate? what causes this?
Begins during 1st trimester;
| Related to progesterone production during atony of calyces and ureters
62
Renal changes: Ureters hold how many times their normal volume (300 mL) of urine
25x
63
Renal changes: bladder tone decr/incr?
decr
64
Renal changes: Increased GFR by what %? Peaks around which weeks of gestation, falls as term approaches
50%;
| at 9-16 weeks
65
Renal changes: GFR changes with changes in what CV parameter?
cardiac output
66
Renal changes: is Proteinuria and glycosuria pathologic in parturient?
no
67
Renal changes: GFR returns to normal within how many weeks postpartum
3 weeks
68
Liver and gallbladder changes: there is a Mild decrease serum albumin level due to what?
expanded plasma volume
69
Liver and gallbladder changes: what% decrease in serum pseudocholineserase activity present at term? does it produce prolongation of sux action? Pseudocholinesterase returns to normal how many weeks postpartum
25 – 30%;
rarely;
2-6 weeks
70
Liver and gallbladder changes: what inhibits the release of cholecystokinin resulting in poor emptying of the gall bladder? Pregnancy predisposes to what gallbladder issue?
High progesterone levels;
| gallstone formation
71
Heme changes: Pregnancy is associated with hypercoagulable state. How is this beneficial?
limiting blood loss during delivery;
72
Heme changes: Increase in what 4 factors and blood product? what factor may decr?
```
Increased fibrinogen (Factor 1), factor VII, factor X, factor XII, and platelets;
XI
```
73
Heme changes: The coagulation profile returns to normal how many weeks postpartum
2 weeks
74
Heme changes: hypercoagulability places Parturients at higher risk for what?
embolus
75
Heme changes: Increased clotting levels coupled with venous pooling puts patient at risk for what?
DVT
76
Heme changes: can Thrombocytopenia be seen in a normal pregnancy
yes
77
Heme changes: what event remains one of the leading causes of maternal mortality
Thromboembolic events
78
Heme changes: In the nonpregnant state, fibrinogen levels average from 200-400 mg/dl. In late pregnancy, levels are normally at least what mg/dL? and may be as high as what mg/dL?
400 mg/dL;
| 650 mg/dL
79
Heme changes: The platelet count remains stable (this contradicts an earlier slide) or is decreased slightly in what trimester?
3rd trimester
80
Heme changes: The WBC count decr/incr in pregnancy. In 3rd trimester, the mean is 10.5K, and in labor the WBC may increase to what?
incr;
| 20-30K
81
GI changes: Increased incidence of what 2 complications?
GERD and aspiration
82
GI changes: Upward displacement of stomach results in what 2 findings/
possible decreased emptying and decreased sphincter tone
83
GI changes: Increased levels of what substance excreted by the placenta causes increased acid secretion
gastrin
84
GI changes: ALL PREGNANT PATIENTS ARE A FULL STOMACH at what point in pregnancy?
from 8 weeks of pregnancy until 6 weeks postpartum
85
GI changes: what is Mendelson’s syndrome? Most parturients have a stomach pH what mL.
Chemical pneumonitis caused by aspiration during general anesthesia, especially during pregnancy;
pH 25 mL.
86
GI changes, aspiration: preventative tx includes what to neutralize stomach acidity? what is given to increase lower esophageal sphincter tone and increase gastric emptying?
bicitra or H2 blockers;
| PPIs (reglan)
87
MS changes: what hormone increases resulting in pain
Relaxin
88
MS changes: what increase in flexibility (consider this in regional technique)
Joints and ligaments
89
MS changes: Increased incidence of what type of spinal curvature?
lumbar lordosis
90
Uterine changes: A non pregnant uterus typically receives about 50 ml/ min of blood flow compared to what ml/min in the pregnant uterus? that is what % of CO?
700 ml/min;
| 10% of CO
91
Uterine changes: Fetal gas exchange is completely dependent upon what perfusion pressure?
maternal uterine perfusion pressure
92
Uteroplacental circulation: what causes intrauterine growth retardation and can result in fetal demise
Uteroplacental insufficiency
93
Uteroplacental circulation: what are the Two key components
uterine BF and placental function
94
Uterine BF: T/F Uterine vasculature is maximally dilated under normal conditions and has a lot capacity to further dilate.
False, no autoregulation
95
Uterine BF: uterine blood flow is determined by what equation?
Uterine arterial pressure – Uterine venous pressure/ uterine vascular resistance
96
Uterine BF: what can reduce uterine blood flow and cause fetal hypoxia and acidosis
Extreme hypocapnia (PaCO2
97
Uterine BF: what are the three events that primarily determine (decrease) uterine blood flow and their causes?
Hypotension: most commonly d/t aortocaval compression, hypovolemia, and sympathetic blockade
Uterine vasoconstriction: caused by stress-induced release of endogenous catecholamines during labor and any drug with alpha-adrenergic activity (phenylephrine)
Contractions: decreases blood flow by elevating uterine venous pressure. Hypertonic contractions during Pitocin infusions can critically compromise uterine blood flow
98
Uterine BF: Aortocaval compression occurs after what week when the patient is in supine position
the 28th week
99
Placental exchange: what is the placental function (3)?
the fetus depends on the placenta for respiratory gas exchange, nutrition, and waste elimination
100
Placental exchange: what is Placental composition? what lies within the villi that are able to exchange substances with the maternal blood that bathe them in this arrangements?
```
Fetal tissue (villi) that lies in the maternal vascular space (intravillous spaces);
Fetal capillaries
```
101
Placental exchange: what sends oxygen poor blood to the placenta/ mom to be oxygenated
umbilical arteries (2)
102
Placental exchange: Water moves across by this method. Movement occurs related to hydrostatic or osmotic gradient
a. diffusion
b. bulk flow
c. active transport
d. pinocytosis
e. breaks in placental membrane
b
103
Placental exchange: Large molecules (immunoglobulins) move across by this method. There is a binding of a specific receptor on a cell surface and it is then enclosed on the plasma membrane
a. diffusion
b. bulk flow
c. active transport
d. pinocytosis
e. breaks in placental membrane
d
104
Placental exchange: Respiratory gasses and small ions are transported by diffusion. Most anesthetic drugs have molecular weights well under 1000 Dalton and consequently diffuse across the placenta. No energy is needed for this process
a. diffusion
b. bulk flow
c. active transport
d. pinocytosis
e. breaks in placental membrane
a
105
Placental exchange: Amino acids, vitamins, and some ions (Calcium and iron) utilize this method
a. diffusion
b. bulk flow
c. active transport
d. pinocytosis
e. breaks in placental membrane
c
106
Placental exchange: mixing of maternal and fetal blood are probably responsible for Rh sensitization
a. diffusion
b. bulk flow
c. active transport
d. pinocytosis
e. breaks in placental membrane
e
107
stages of labor: from 10cm dilated until the delivery of the baby is complete (pushing stage)
a. first
b. first, latent
c. first, active
d. second
e. third
d
108
stages of labor: more frequent contractions (3-5 minutes) and progressive cervical dilation up to 10 cm.
a. first
b. first, latent
c. first, active
d. second
e. third
c
109
stages of labor: Progressive cervical effacement and minor dilation (2-3 cm) “soft and thin”
a. first
b. first, latent
c. first, active
d. second
e. third
b
110
stages of labor: Delivery of baby until placenta is delivered
a. first
b. first, latent
c. first, active
d. second
e. third
e
111
stages of labor: regular contractions until fully dilated (10 cm)
a. first
b. first, latent
c. first, active
d. second
e. third
a
112
stages of labor & pain pathways: Nociceptor stimulation is mediated by C fibers (Small, unmyelinated nerves).
a. first
b. second
a
113
stages of labor & pain pathways: Pain travels via the pudendeal nerves, they enter the spinal cord at S2 – S4
a. first
b. second
b
114
stages of labor & pain pathways: Pain travels via visceral afferents accompanying sympathetic nerves as they enter the spinal cord at T10 – L1
a. first
b. second
a
115
stages of labor & pain pathways: This pain is caused by distention of lower vagina, vulva, and perineum epidural may not cover this
a. first
b. second
b
116
stages of labor & pain pathways: Cervical dilation and effacement and possibly uterine muscle ischemia during contraction causes this pain.
a. first
b. second
a
117
Labor anes pearls: which anes techniques are by far preferred over general anesthesia/ parenteral narcotics
Regional
118
Labor anes pearls: location of analgesia for First stage of labor? second stage location?
~ T10 – L1;
| ~ T10 – S4
119
Labor anes pearls: which regional anes techniques are preferred over other regional techniques
Continuous epidural analgesia (CEA) infusions
120
Labor anes pearls: does CEA in dilute doses have much of an effect on progress of labor
no, has little effect
121
Labor anes pearls: why is the Incidence of inadvertent intravenous injection high? tx?
bc all vessels are engorged;
| Tx: lipid emulsion for LA tox
122
Labor anes pearls: Hypotension is common and must be treated aggressively with what?
fluid & ephedrine
123
Indications for a c-section: Immediate or emergent delivery necessary in what 5 conditions/scenarios?
fetal distress, Umbilical cord prolapse, Maternal hemorrhage, Amnionitis, Genital herpes with ruptured membranes Impending maternal death
124
Pregnancy HTN: Pregnancy induced hypertension (PIH) is defined as a SBP >what mmHg, DBP >what mmHg
SBP >140 mmHg, DBP >90 mmHg
125
PIH: PIH more accurately describes one of what three syndromes?
preeclampsia, eclampsia, and the HELLP syndrome
126
PIH: hypertension, proteinuria, peripheral edema, plus Hemolysis, Elevated Liver Enzymes, and a Low Platelet Count
a. preeclampsia
b. eclampsia
c. HELLP syndrome
c
127
PIH: Triad of hypertension, proteinuria, and peripheral edema
a. preeclampsia
b. eclampsia
c. HELLP syndrome
a
128
PIH: hypertension, proteinuria, peripheral edema, and seizures
a. preeclampsia
b. eclampsia
c. HELLP syndrome
b
129
PIH: Patient c/o epigastric pain, malaise, N&V
a. preeclampsia
b. eclampsia
c. HELLP syndrome
c
130
PIH: Definitive treatment is delivery of fetus
a. preeclampsia
b. eclampsia
c. HELLP syndrome
b
131
PIH: 20% have decrease in clotting factors
a. preeclampsia
b. eclampsia
c. HELLP syndrome
a
132
PIH: Leading cause of maternal mortality
a. preeclampsia
b. eclampsia
c. HELLP syndrome
b
133
PIH: Usually occurs after 24 weeks gestation
a. preeclampsia
b. eclampsia
c. HELLP syndrome
a
134
PIH: Usually occurs after 36 weeks
a. preeclampsia
b. eclampsia
c. HELLP syndrome
c
135
PIH: Hepatic rupture possible
a. preeclampsia
b. eclampsia
c. HELLP syndrome
c
136
PIH: Higher incidence in: African-American women, extremes of age, multiple gestation, DM
a. preeclampsia
b. eclampsia
c. HELLP syndrome
a
137
PIH: tx is Immediate delivery regardless of fetal gestation
a. preeclampsia
b. eclampsia
c. HELLP syndrome
c
138
PIH: Can start as mild and rapidly progress including DIC
a. preeclampsia
b. eclampsia
c. HELLP syndrome
c
139
PIH: Management involves: Magnesium sulfate gtt to increase seizure threshold, Anti-hypertensives (hydralazine), BB
a. preeclampsia
b. eclampsia
c. HELLP syndrome
b
140
PIH: tx Thiopental, benzodiazepines, magnesium to stop seizure
a. preeclampsia
b. eclampsia
c. HELLP syndrome
b
141
PIH preeclampsia: mild form SBP what range, DBP what range. +? edema, trace proteinura
SBP 140-160, DBP 90-110. +1 edema, trace proteinura
142
PIH preeclampsia: severe form is SBP >what, DBP >what, > +?edema, > how much gm proteinura in 24 hours
SBP >160, DBP >110, > +2 edema, > 5gm proteinura in 24 hours
143
Preeclampsia anes mgmt: is regional is appropriate?
yes, once clotting factors are checked
144
Preeclampsia anes mgmt: how avoid HOTN when administering regional?
After test dose of epi, administer bolus in divided doses and infuse fluids to avoid HOTN
145
Eclampsia: what is the only way to resolve it?
deliver baby
146
what does HELLP stand for?
H- hemolytic anemia
EL- elevated liver enzymes
LP- low platelets
147
Placenta previa: defined as?
when placenta obstructs fetal presentation
148
Placenta previa: what causes it?
Unknown etiology but more common in multiparous patients and previous c-section
149
Placenta previa: Partial when part of what is covered? Marginal when placental edge is where?
cervical os;
| at os
150
Placenta previa: what are the symptoms?
Symptom is painless vaginal bleeding
151
Placenta previa: must do c-section?
yes
152
Abnormal placental implantations: what are the 3 types?
accreta, increta, and percreta
153
Abnormal placental implantations: Erodes myometrium, can invade bowel, bladder etc.. Probable hysterectomy
a. accreta
b. increta
c. percreta
c
154
Abnormal placental implantations: Abnormally adheres to surface of myometrium (muscle layer)
a. accreta
b. increta
c. percreta
a
155
Abnormal placental implantations: Invades myometrium
a. accreta
b. increta
c. percreta
b
156
Abnormal placental implantations: Higher incidence of what for mom
venous embolus
157
Abruptio placentae: defined as separation of placenta after how many weeks
20
158
Abruptio placentae: higher incidence with what (4)?
PIH, HTN, smoking, cocaine use, uterine abnormalities
159
Abruptio placentae grades: moderate, same as grade 1 but with fetal distress
a. 0
b. 1
c. 2
d. 3
c
160
Abruptio placentae grades: severe, maternal shock, uterine tetany, DIC, fetal demise
a. 0
b. 1
c. 2
d. 3
d
161
Abruptio placentae grades: no signs or symptoms, recognized after delivery
a. 0
b. 1
c. 2
d. 3
a
162
Abruptio placentae grades: mild, painless bleeding, abdominal pain, contractions
a. 0
b. 1
c. 2
d. 3
b
163
Amniotic fluid embolus (AFE): what happens when it occurs? when can it occur?
Occurs when amniotic fluid enters maternal circulation from any break in uteroplacental integrity;
Can occur during labor, delivery, c- section, or postpartum
164
Amniotic fluid embolus (AFE): common?
no but 50% mortality in first hr
165
Amniotic fluid embolus (AFE): DIC occurs in what% after first hour
80%
166
Amniotic fluid embolus (AFE): Anaphylaxis type reaction caused by what?
from debris
167
Amniotic fluid embolus (AFE):
a. RR
b. pulm bp
c. O2
d. CV
e. coagulation
a. RR: sudden tachypnea
b. pulm bp: pulmonary HTN,
c. O2: Hypoxia
d. CV: cardiovascular collapse
e. coagulation: coagulopathy
168
Amniotic fluid embolus (AFE): Usually occurs during what stage of delivery?
labor and delivery or within 30 minutes of delivery
169
Amniotic fluid embolus (AFE): Definitive diagnosis is usually discovered when?
post-mortum
170
Amniotic fluid embolus (AFE): tx and goal (2)?
supportive;
| goal is to maintain perfusion and correct coagulopathy
171
Uterine rupture: common? Most likely to occur after when?
no;
| VBAC and uterine manipulation (version)
172
Retained placenta: diagnosed how?
Continued bleeding after delivery
173
Retained placenta: tx? what is the common anes techique for the tx?
D&C;
| commonly done with regional anesthesia
174
Retained placenta: follow what lab closely?
hgb
175
Prolapsed cord: defined as?
Umbilical cord protrudes out of cervix ahead of the fetus
176
Prolapsed cord: what compresses the cord and results in decreased perfusion and oxygen to the fetus
Each contraction and pushing
177
Prolapsed cord: tx until c-section is performed?
Someone will need to lift the head off the cord and proceed to c-section
178
Multi gestation: Increase requirement of higher intrathecal doses is due to what?
increase in CSF
179
Multi gestation: why is an epidural is probably a good idea in this population (3 reasons)?
Good pain management
Easier manipulation of fetus if needed
Provides a means to facilitate a c-section if needed.
180
GA c-section: is de-fasiculation unnecessary before sux?
no
181
GA c-section: doses
a. prop
b. sux
c. ketamine
a. 2mg/kg
b. 1.5mg/kg
c. 1mg/kg
182
GA c-section: what med is used instead of thiopental in hypovolemic or asthmatic patients
ketamine
183
GA c-section: what med may be more likely to produce maternal hypotension and neonatal depression
midaz
184
GA c-section: Surgery is begun only after what is verified?
proper placement of the endotracheal tube is confirmed by capnography
185
GA c-section: why avoid hyperventilation (PaCO2, 25 mm Hg)
because it can reduce uterine blood flow and has been associated with fetal acidosis
186
GA c-section: what is your O2% mix?
50/50 N2O and O2
187
GA c-section: up to what MAC of a volatile agent for maintenance. Why that level?
0.75 MAC;
The low dose of volatile agent helps ensure amnesia but is generally not enough to cause excessive uterine relaxation or prevent uterine contraction following oxytocin.
188
GA c-section: use a MR of what duration?
A muscle relaxant of intermediate duration for relaxation
189
GA c-section: After the neonate and placenta are delivered, what med and dose is added to each liter of intravenous fluid
20–30 U of oxytocin
190
GA c-section: If the uterus does not contract readily, switch to a balanced technique and discontinue what?
the volatile agent
191
GA c-section: what other 2 meds with doses and routes to have ready for poor uterine tone? Which one may incr arterial BP?
Methylergonovine (Methergine), 0.2 mg IM
15-Methylprostaglandin F2 (Hemabate), 0.25 mg IM;
Methergine
192
C-section pearls: Sensory level for spinal must reach what level? This is at the level of the patient’s nipples. What causes HOTN after administration?
T4;
| A sensory block this high effectively anesthetizes the sympathetic outflow.
193
C-section pearls: why does spinal or epidural anesthesia carries far less risk for maternal mortality than general anesthesia?
d/t airway loss
194
C-section pearls: which is easier to perform, spinal or epidural? however, what are the side effects?
Spinal easier;
| but has less control than epidural and a more rapid decrease in BP
195
C-section pearls: Pretreat regional with crystalloid bolus of what ml or colloid bolus of what ml?
1000 - 1500ml;
| 250 – 500ml
196
Which of the following is not acceptable for indxn of anes for c-section
a. Thiopental
b. Prop
c. Sux
d. Nimbex
d
197
Rapid admin of oxytocin can cause what severe untoward side effect
a. HOTN
b. HTN
c. SB
d. Anaphylaxis
a
198
Hemabate (synthetic prostaglandin F/Carboprost) can cause what severe untoward SE if given IV
a. Anaphylaxis
b. SB
c. HOTN
d. Bronchospasm
d
199
Pts on mg sulf gtt for preterm labor can experience what difficulty with potentiating of drugs used for GA?
Increased resp depression and nausea in conjunction with opioids and you will need less MR due to weakened muscles
200
Which of these LA drugs is least likely to undergo ion trapping in an acidotic fetus
a. Lido
b. Bupiv
c. Ropiv
d. Chloroprocaine
D bc it is an ester
201
Pregnancy induced HTN (PIH) is defined as
a. SBP >140
b. SBP >150
c. SBP >160
d. SBP >170
a
202
Pre-eclampsia is defined as PIH with
a. Preterm labor and edema
b. Preterm labor and hypercoagulability
c. Edema and hypercoagulability
d. Preterm labor and proteinuria
e. Edema and proteinuria
e
203
1. Definitive tx for preeclampsia is
a. Hydralazine
b. Mg sulf gtt
c. Delivery
d. Epidural analgesia
c
204
What ominous sign determines when the parturient becomes eclamptic
a. Devel of coagulopathies
b. SBP >190
c. CVA
d. Seizures
d
205
What does the HELPP syndrome stand for
HTN
ELevated liver enzymes
Low Plts
206
Case scenario: you have placed an epidural in a healthy 29 yr old gravid 1, para 0. She is now 6cm dilated and partially effaced. You are STAT paged back to L&D. The woman is sitting bolt upright in bed with sudden onset of tachpnia and ST. The BP is still cycling, you cannot palpate a femoral pulse. You note pink, frothy secretions manifesting. She is devel wheals that appear like anaphylaxis. What is your tentative diagnosis?
a. Acute papillary muscle rupture
b. Eclampsia
c. PE
d. Amniotic fluid embolism
d
207
You are presented with a 32 year old pt, gravid 2, para 1 in her first tri for urgent chole. Which of these drugs should be avoided
a. Thiopental
b. Midaz
c. Fent
d. Roc
b
208
BV increases during pregnancy but the pregnant pt will have a ________ anemia
a. Nutritional
b. Iron deficiency
c. B12 deficiency
d. Dilutional
d
209
Which of the following is true abt the effect of inhalational anes on uterine tone
a. Inhalational anes increase uterine tone
b. Inhalational anes at 1 MAC or above have min effect on uterine tone
c. Inhalational anes incr intracellular Ca and can cause contractions
d. The degree of uterine atony is a dose dependent effect of inhalation anes
d
210
In the pregnant at term, FRC, ER, and RV are
a. Incr
b. Decr
b
211
High metabolic O2 demand and low functional reserve create conditions for which of the following
a. Aspiration pna
b. Leftwards shift of oxyhemoglobin dissociation curve
c. Increased incidence of difficult airways
d. Rapid desat during indxn of anes
e. All of the above
d
212
At term, the pregnant pt may experience airway edema, making intubation difficult
a. True
b. False
a
213
What maneuver can reduce the incidence and impact of aortocaval compression in the pregnant pt?
a. Reverse T-berg
b. T-berg
c. Left uterine displacement
d. Right uterine displacement
c
214
Based upon what you know abt MAC and the physiologic changes of pregnancy, is MAC decreased in pregnancy
a. True
b. False
a
215
Which of these blocks carries a risk of inadvertently injecting LA into the fetal scalp?
a. Paracervical
b. Saddle block
c. Caudal single shot
d. Pudendal block
a
216
Highly ionized drugs readily cross the placental barrier
a. True
b. False
b
217
FHR is typically monitored during labor. Which of these fetal HR patterns may indicate fetal acidosis?
a. Early decels
b. HR variability (reactivity)
c. Late decels
d. Acceleration of HR
c
218
Case study: You are presented with a 32 yr old gravid 3, para 0, who was sent directly from the OB/GYN office with evidence of cervical shortening and dilation to 2cm at 20 wks. She has a h/o 2 previous 2nd trimester spontaneous abortions at 22 and 21 weeks gestation. She is added to the schedule for an urgent cervical cerclage procedure for incomplete cervix.
PMH: essentially benign, no previous surgeries and no medical conditions
Meds: prenatal vitamins
Wt: 78kg, 166cm
VS: BP 122/66, HR 82, RR 18, SaO2 98% RA
Is this pt at risk for aortocaval compression?
a. Yes
b. No
b
219
Case study: You are presented with a 32 yr old gravid 3, para 0, who was sent directly from the OB/GYN office with evidence of cervical shortening and dilation to 2cm at 20 wks. She has a h/o 2 previous 2nd trimester spontaneous abortions at 22 and 21 weeks gestation. She is added to the schedule for an urgent cervical cerclage procedure for incomplete cervix.
PMH: essentially benign, no previous surgeries and no medical conditions
Meds: prenatal vitamins
Wt: 78kg, 166cm
VS: BP 122/66, HR 82, RR 18, SaO2 98% RA
One advantage of spinal or epidural anes for this pt is
a. Decr blood loss
b. Abolishing the s/sxs of bladder perforation during the procedure
c. Pre-emptive analgesia
d. Minimizing the number and amts of drugs admin to accomplish the anesthetic
d
220
Case study: You are presented with a 32 yr old gravid 3, para 0, who was sent directly from the OB/GYN office with evidence of cervical shortening and dilation to 2cm at 20 wks. She has a h/o 2 previous 2nd trimester spontaneous abortions at 22 and 21 weeks gestation. She is added to the schedule for an urgent cervical cerclage procedure for incomplete cervix.
PMH: essentially benign, no previous surgeries and no medical conditions
Meds: prenatal vitamins
Wt: 78kg, 166cm
VS: BP 122/66, HR 82, RR 18, SaO2 98% RA
The pt will be in lithotomy position during the procedure. What must the anesthetist be vigilant for when the pt is returned to a supine position
a. Vomiting
b. SB
c. Fetal ST
d. Maternal HOTN
d
221
Case study: You are presented with a 32 yr old gravid 3, para 0, who was sent directly from the OB/GYN office with evidence of cervical shortening and dilation to 2cm at 20 wks. She has a h/o 2 previous 2nd trimester spontaneous abortions at 22 and 21 weeks gestation. She is added to the schedule for an urgent cervical cerclage procedure for incomplete cervix.
PMH: essentially benign, no previous surgeries and no medical conditions
Meds: prenatal vitamins
Wt: 78kg, 166cm
VS: BP 122/66, HR 82, RR 18, SaO2 98% RA
Your pt is very emotional abt having this procedure. She is crying. Would you give her Midaz to help control her emotional state?
a. Yes
b. No
b
222
Case study: You are presented with a 32 yr old gravid 3, para 0, who was sent directly from the OB/GYN office with evidence of cervical shortening and dilation to 2cm at 20 wks. She has a h/o 2 previous 2nd trimester spontaneous abortions at 22 and 21 weeks gestation. She is added to the schedule for an urgent cervical cerclage procedure for incomplete cervix.
PMH: essentially benign, no previous surgeries and no medical conditions
Meds: prenatal vitamins
Wt: 78kg, 166cm
VS: BP 122/66, HR 82, RR 18, SaO2 98% RA
During placement of the lumbar epidural, you get a “wet tap”. You are concerned abt the devl of a PDPH. What is the hallmark characteristics of a PDPH?
a. It is postural
b. It is throbbing
c. It is accompanied by an aura
d. It is most severe around the eyes
a
223
What is the incidence of failed intubation in the pregnant pt undergoing c-section at term?
a. 1/2500
b. 1/250
c. 1/1000
d. 1/600
b
224
At the term of pregnancy, CO increases by ___%?
a. 20
b. 30
c. 40
d. 50
c
225
At term of pregnancy, ____% of CO perfuses the gravid uterus
a. 10
b. 20
c. 30
d. 40
a
226
In which position does aortocaval compression mostly occur
a. Left lateral decub
b. Right lateral decub
c. Supine
d. Beach chair
c
227
Select one respiratory vol that increases during pregnancy
a. TLC
b. RV
c. FRC
d. TV
d
228
epidural labor mgmt PP: Infection at the site of needle placement
a. absolute contraindication
b. relative contraindiction
a
229
epidural labor mgmt PP: Frank Coagulopathy
a. absolute contraindication
b. relative contraindiction
a
230
epidural labor mgmt PP: Increased Intracranial pressure
a. absolute contraindication
b. relative contraindiction
a
231
epidural labor mgmt PP: Poor staffing
a. absolute contraindication
b. relative contraindiction
b
232
epidural labor mgmt PP: Relative (and correctable) hypovolemia
a. absolute contraindication
b. relative contraindiction
b
233
epidural labor mgmt PP: Severe Hypovolemia
a. absolute contraindication
b. relative contraindiction
a
234
epidural labor mgmt PP: Mild or isolated coagulation abnormalities (HELLP, DIC, PIH with clotting disturbances)
a. absolute contraindication
b. relative contraindiction
b
235
epidural labor mgmt PP: Inability to cooperate
a. absolute contraindication
b. relative contraindiction
a
236
epidural labor mgmt PP: Preexisting neurological deficiency
a. absolute contraindication
b. relative contraindiction
b
237
epidural labor mgmt PP: Decreased FHR variability or late decelerations of FHR
a. absolute contraindication
b. relative contraindiction
a
238
epidural labor mgmt PP: Systemic maternal infection
a. absolute contraindication
b. relative contraindiction
b
239
epidural labor mgmt PP: Patients Refusal
a. absolute contraindication
b. relative contraindiction
a
240
epidural labor mgmt PP: Anticoagulation Therapy
a. absolute contraindication
b. relative contraindiction
a
241
epidural labor mgmt PP: what are the 3 meninge layers and spaces starting from most inner layer closest to spinal cord/brain? which layer is filled with CSF?
pia mater, subarachnoid space, arachnoid mater, dura mater, epidural space;
subarachnoid space
242
epidural labor mgmt PP: what are the contents of the epidural space (5)? in which does opioids and LAs collect in?
fat, epidural veins and arteries, lymphatics, nerve roots;
| fat
243
epidural labor mgmt PP: Medications used in epidurals act on receptors in which horn of the spinal cord? by diffusing across what?
dorsal horn;
| meninges and CSF
244
epidural labor mgmt PP: what is defined as the area of cutaneous sensation supplied by a spinal nerve that is anatomically identifies as it passes through an intervertebral foramen
dermatome
245
epidural labor mgmt PP: the dermatome of the thumb synapses where on the spinal cord? ring/little finger? nipple line? xiphoid? umbilicus? perineal?
```
C6;
C8;
T4;
T6;
T10
S2,3
```
246
epidural labor mgmt PP: why is an epidural failure possible with obese pts or tall pts?
need more vol to reach nerve roots
247
epidural labor mgmt PP: why is an epidural failure possible with h/o previous epidural placement?
scar tissue doesn't allow for penetration of LA
248
epidural labor mgmt PP: epidural failure possible with what position presentation of fetus?
posterior
249
epidural labor mgmt PP: epidural failure possible with duration of labor > how many hrs?
>6hrs
250
epidural labor mgmt PP: name ways to troubleshoot epidural ineffectiveness (9)
```
Manipulate epidural catheter
Add more local anesthetic
Reposition Patient (e.g. lie on painful site and let gravity work)
Replacement of the epidural catheter
A single shot spinal anesthesia
Continuous spinal anesthesia
Combined spinal-epidural anesthesia
Placement of a second epidural catheter
Supplementation with intravenous medications
```
251
epidural labor mgmt PP: if pt has good block density but inadequate segmental level, what are the 4 possible contributors?
1. Small volume of LA
2. Insufficient time
3. Loss of LA (volume)
4. Anatomical factors (previous sx or injury, scoliosis)
252
epidural labor mgmt PP: if pt has good block density but inadequate segmental level due to previous injury, what are the 3 troubleshooting options?
redose with more vol, allow more time, additional epidural
253
epidural labor mgmt PP: if you had a previously well functioning epidural, now appears not to be working, what are the 4 possible reasons?
cath migration, labor progression (will need more vol), dysfunctional labor (not progressing), pt perception changed
254
epidural labor mgmt PP: if you had a previously well functioning epidural, now appears not to be working due to catheter migration, where are the 4 possible areas it may have migrated to?
subarachnoid space, intravasc, laterally (unilateral block), or completely out of epidural space
255
epidural labor mgmt PP: if you had a previously well functioning epidural, now appears not to be working due to pt perception, what are the 4 possible interventions?
examine the catheter, redose with more vol, add opioids or incr % of LA, replace epidural
256
epidural labor mgmt PP: Epidurals are placed typically at what 2 levels?
L3-4 or L4-5
257
epidural labor mgmt PP: First stage of labor is visceral carried by what nerve roots
T-10-L-1 nerve roots
258
epidural labor mgmt PP: what nerve roots Innervate the uterus, cervix and upper portion of the vagina
T-10-L-1
259
epidural labor mgmt PP: Second stage of labor pain is somatic and carried by what nerve roots?
S2-S4 nerve roots
260
epidural labor mgmt PP: what nerve roots innervating the perineum?
S2-S4 nerve roots
261
epidural labor mgmt PP: which stage is more painful?
2
262
epidural labor mgmt PP: why is is more difficult for local anesthetic to penetrate S2-S3 from the epidural?
These nerve roots are further from the tip of the epidural catheter, larger in diameter, and surrounded by thicker dura matter
263
epidural labor mgmt PP: Epidural infusions tend to transverse downward or upward? how can we counteract this?
upward;
| have pt sit up for a bit to allow gravity to help
264
epidural labor mgmt PP, chronic back pain: Patient’s with unilateral or sciatica the affected nerve roots become blocked how many minutes later than the nerves on the contralateral side. The Local anesthetics have a difficult time diffusing into the injured site.
10-70 min later
265
epidural labor mgmt PP: what is the issue with scoliosis pts?
difficult to place epidural and unpredictable LA spread
266
epidural labor mgmt PP: what are the ASRA recommendations on epidurals and coagulation tx regarding oral (e.g. ASA, NSAIDS, heparin)? antiplatelet meds (e.g. plavis)? fibrinolytic and thrombolytic meds?
stop anticoag meds and measure PTT and INR;
does not incr risk of spinal hematoma;
use extreme caution
267
epidural labor mgmt PP: what are the ASRA recommendations regarding SQ hep? reduce risk of bleeding by giving subq heparin at least how long after the spinal or epidural? and Remove catheter how long before subq heparin is given or 2-4 hours after the last dose
not contraindicated;
one hour;
one hour;
268
epidural labor mgmt PP: what are the ASRA recommendations regarding LMWH? In extreme cases in which an epidural or spinal is required, you can give a Single dose spinal how many hours after a dose of LMWH? and Remove catheter prior to starting LMWH how many hours after the last dose of LMWH with subsequent doses given at least two hours after catheter removed?
LMWH places the patient at an increased risk of spinal hematoma;
12hrs;
12hrs
269
epidural labor mgmt PP: what characteristic of opioids influences its onset and duration of action? 2 examples of these?
```
lipid solubility (higher is faster but shorter duration);
fentanyl and merperidine
```
270
epidural labor mgmt PP: is morphine and hydromorphone lipid soluble?
no, water soluble
271
epidural labor mgmt PP: what is the diffusion, onset, and duration of water soluble meds?
diffusion and onset is slower but duration is longer
272
epidural labor mgmt PP: which has greater dermatomal spread, lipophilic or hydrophilic?
hydrophilc
273
epidural labor mgmt PP: morphine
a. lipid solubility
b. onset
c. duration
a. lipid solubility 1
b. onset 30-60min
c. duration 6-24hrs
274
epidural labor mgmt PP: dilaudid
a. lipid solubility
b. onset
c. duration
a. lipid solubility 10
b. onset 15-30min
c. duration 6-18hrs
275
epidural labor mgmt PP: fentanyl
a. lipid solubility
b. onset
c. duration
a. lipid solubility 800
b. onset 5min
c. duration 4-6hrs
276
epidural labor mgmt PP: there are 2 distinct times when Hydrophilic opioids(morphine, hydromorphone) causes respiratory depression (early and delayed). when do each occue?
Early respiratory depression: soon after administration
| and delayed may occur up to 24hrs after administration
277
epidural labor mgmt PP: when do lipophyllic meds cause respiratory depression?
early onset after administration due to easy penetration and uptake
278
epidural labor mgmt PP: when is the patient at great risk for respiratory depression and death?
if IV, IM or PO opioids are given with an infusing epidural
279
epidural labor mgmt PP: why is N/V a SE of epidural opioid? why pruritis?
Due to the rostral spread of the opioid in the CSF to the chemoreceptor trigger zone in the brainstem;
unknown
280
epidural labor mgmt PP: how do LA block nerve condxn?
inhibiting Na influx thru Na channels which results in the inability to modulate pain while maintaining motor function
281
epidural labor mgmt PP: is it possible to produce a motor block with LAs? if so, how?
yes, increase vol and % of LA into the epidural space
282
epidural labor mgmt PP: what is a common epidural LA for infusions? what is the onset and duration?
ropivicaine;
| quick onset and long duration
283
epidural labor mgmt PP: which LA provides the best sensory block with minimal motor block?
ropivicaine
284
epidural labor mgmt PP: what causes systemic LA toxicity?
high blood concentrations of LAs
285
epidural labor mgmt PP, LA tox: what are the 4 things that affect the blood concentrations?
dose, site of injection, speed of injection, inadvertent vessel injection
286
epidural labor mgmt PP, LA tox: Classically, systemic toxicity begins with symptoms of what system?
CNS
287
epidural labor mgmt PP, LA tox: name 4 CNS sxs.
lightheadedness, dizziness, metallic taste, ringing in ears
288
epidural labor mgmt PP, LA tox: when CNS sxs progress to an excitatory phase what are the symptoms (4)?
(think moter) shivering, muscle twitching, tremors convulsions
289
epidural labor mgmt PP, LA tox: what are the 3 CV sxs?
HOTN, myocardial depression, cardiac arrest
290
epidural labor mgmt PP, LA tox: what are the 3 interventions?
lipid rescue, O2, supportive measures (e.g. ACLS, CPR, fluids)
291
epidural labor mgmt PP: Once the provider feels as if he or she has entered the epidural space the provider will do what?
give a test dose of the local anesthetic
292
epidural labor mgmt PP: what is the typical meds for an epidural infusion?
a. what is the continuous dose range
b. bolus dose and max per hr
c. max mL per hour
fentanyl 2mcg/mL with ropiv .2%
a. what is the continuous dose range 7-14cc/hr
b. bolus dose 4cc and max bolus 3cc per hr
c. max mL per hour 26mL
293
epidural labor mgmt PP: If patient desires epidural analgesia, oral intake must be limited to what?
clear liquids only
294
epidural labor mgmt PP: Provide 1:1 nursing care during the epidural placement and for the first how many minutes thereafter
30 minutes
295
epidural labor mgmt PP: Pulse oximetry should be used continuously during the what doses? Monitor and record SaO2 a minimum how frequently if the patient is stable
test dose and initial bolus period;
| once q 1 hour
296
epidural labor mgmt PP: what is the frequency of BP monitoring after initiation of epidural? after each bolus? is Continuous fetal monitoring required while the epidural is infusing?
Record blood pressure every 5 minutes X 4, every 15 minutes x 2, then every 30 minutes provided the patient is stable while the epidural is infusing;
every 5 minutes x 4;
yes
297
epidural labor mgmt PP: If the patient becomes hypotensive, attempt what 2 interventions?
1) Give ephedrine
| 2) Reposition the patient
298
epidural labor mgmt PP: If indeterminate or abnormal FHR patterns are identified, do what 3 things?
initiate intrauterine resuscitative measures (maternal position change, IV fluid bolus, oxygen administration at 10 L via non-rebreather face mask)
299
epidural labor mgmt PP: If excessive uterine activity occurs, initiate what 2 things? If these measures are ineffective, consider decreasing or discontinuing the what (if infusing)? Notify the OB and anesthesia providers
maternal repositioning and IV fluid bolus;
| oxytocin
300
epidural labor mgmt PP: Evaluate the postpartum woman’s readiness to ambulate and potential fall risk. All ambulation should be assisted and observed for how many hours after the infusion is stopped
4 hrs after
301
epidural labor mgmt PP: what is a key finding of a PDPH? Interventions (2)?
```
positional HA (increased pain in the upright position that is relieved in the supine position);
increase oral fluid intake, encourage caffeinated beverages
```
302
epidural labor mgmt PP: Intervention for urinary retention (2)?
Bladder scan if unable to void. Straight cath if needed
303
epidural labor mgmt PP: how assess pt's level of epidural/sensory changes with cold?
Touch patient’s skin at shoulder with alcohol wipe along side mid-clavicular line. Ask if alcohol feels cold. Move downward, testing every 1-2 inches until patient perceives wipe as warm. Level should be between T-8 and T-10 (between umbilicus and lower than xiphoid
304
epidural labor mgmt PP: how assess patient’s motor strength? how soon after epidural initiation? then how frequently?
ability to lift legs on both sides;
3o minutes;
Every 1-2 hours
305
epidural labor mgmt PP: interventions if Respiratory rate less than 8 per minute or a score of 3 or less on the awake/sedation scale
Shut off epidural infusion
Initiate Narcan Protocol
Notify Anesthesia Stat
306
epidural labor mgmt PP: intervention if Patient unable to feel cold at level of xiphoid and block above desired level
Shut off epidural infusion
| Notify anesthesia
307
non ob sx PP: which trimester is safest to do sx?
second
308
non ob sx PP: why Avoid manipulation of uterus?
to prevent pre-term labor
309
non ob sx PP: what is the optimal anes technique/plan?
Optimal is regional with limited drug use
310
non ob sx PP: avoid what 3 meds?
NSAIDs, nitrous, benzodiazepines
311
non ob sx PP: when is version done?
when fetus has breech presentation
312
non ob sx PP, version: what type of anes is this typically done under?
epidural anesthesia but will sometimes be attempted without
313
non ob sx PP, version: at how many wks can this be done?
Can be done anytime between 36-38 weeks but before onset of labor
314
non ob sx PP version: Done on OB floor but, OR should be ready in event of what?
uterine rupture
315
non ob sx PP: what causes PDPH?
Unintentional puncture of the dura resulting in a slow CSF leak
316
non ob sx PP, PDPH: Treatment is most effective after how many hrs?
AFTER 24 hours
317
non ob sx PP, PDPH: 4 possible txs?
fluids, NSAIDS, caffeine, blood patch
318
non ob sx PP, PDPH: when is a blood patch attempted? what is the success rate of relief when done?
done if all other txs are unsuccessful;
| Blood patch-relief (if successful) is nearly immediate in 90-95% of cases
319
non ob sx PP, PDPH: what is one the most important factors?
Needle size-use smaller one
320
non ob sx PP, PDPH blood patch: Basically, the exact same as placing what?
an epidural
321
non ob sx PP, PDPH blood patch: Instead of placing an epidural catheter, what is injected instead?
20ml of the patient’s own blood is injected
322
non ob sx PP, PDPH blood patch: how long for relief to set in?
almost immediate
323
non ob sx PP, PDPH blood patch: where inject?
Inject at the same level as the unintended puncture [see bruising and puncture site(s)].
324
non ob sx PP, PDPH blood patch: why inject 20ml?
The 20 ml should spread to cover an additional level if you guessed incorrectly
325
non ob sx PP, PDPH blood patch: The patient should lay flat for how many minutes to allow spread of the patch and clot to form
30 min
326
non ob sx PP: Your patient has requested analgesia for labor. Stage I latent
She is 22 y/o primip currently dilated to 4cm. What options can you offer her and why?
Fentanyl, epidural, not intrathecal (not last long enough 1-2hrs)
327
non ob sx PP: Your patient is a multip dilated to 7cm and extremely uncomfortable.
She had an epidural with her last delivery and would like one again.
Since her last delivery, she mentions she has had a L5-S1 fusion (low incision).
What do you tell her?
Epidural may not cover d/t scar tissue
328
non ob sx PP: Your patient is 17 y/o and in active labor.
She is accompanied by her boyfriend.
She is unable to sit still and is screaming
What options do you have? Can you obtain consent from her?
Epidural, talking her down;
| yes
329
pharm for OB pts PP: which is the gold standard sedative for indxn?
prop
330
pharm for OB pts PP: which indxn med is not a first line choice for induction, but is acceptable and safe.
Bronchodilator properties are helpful
ketamine
331
pharm for OB pts PP: why avoid ketamine in preeclampsia?
Catecholamines cause uterine vasoconstriction, but an INCREASE in blood flow to the uterus is seen
332
pharm for OB pts PP, ketamine: Neonatal depression is not seen until doses reach how much mg/kg
1 mg/kg
333
pharm for OB pts PP: what MR is the absolute standard for muscle relaxation for intubation in all obstetrics cases? Why?
sux;
| Fast, RSI
334
pharm for OB pts PP: why remember to dose succinylcholine cautiously?
for pseudocholinesterase insufficiency due to incr BV
335
pharm for OB pts PP: do opioids cross placenta? fent dose recommendation?
All opioids are lipid soluble and small, and cross rapidly to placenta;
Dose: 50-100 mcq Q hour
336
pharm for OB pts PP: which opioids has a higher incidence of neonatal depression?
morphine
337
pharm for OB pts PP: Benzodiazepines are
| contraindicated in which trimester
first
338
pharm for OB pts PP: why are NDMR not good for indxn?
need RSI, full stomach
339
pharm for OB pts PP: do Volatile Agents cross placenta? which one is best? since All cause dose dependent decrease in uterine blood flow, what is a great alternative? how else do they affect the uterus?
yes, all of them;
all equal but iso used most often;
TIVA great alternative;
uterine relaxation
340
pharm for OB pts PP: 2/3 Mac inhalation agent depresses uterine contractility approximately what%. how overcome this?
25%;
| pitocin
341
pharm for OB pts PP: what is the First line drug given in all cesarean sections immediately after delivery of the placenta to stop bleeding?
oxytocin
342
pharm for OB pts PP: how does oxytocin affect the uterus? onset of action?
uterine contraction;
| 1min if IV
343
pharm for OB pts PP, oxytocin: Typical dose (non-emergent) how many units? In acute bleeding, how many units?
20units;
| 40 units
344
pharm for OB pts PP, oxytocin: dilute in what? IVP?
1L crytstalloid;
| never
345
pharm for OB pts PP, oxytocin: Rapid administration can result in what due to preservative in pitocin?
hypotension and tachyardia
346
pharm for OB pts PP: example of an ergot alkaloid to stop bleeding?
methergine
347
pharm for OB pts PP: what is methergine route, dose, onset? IV okay? If given IV, what is the possible SE?
Typically given 0.2 mg intramuscularly, with a 3-5 minute onset;
Can be given IV at a dose of 0.02mg but not typically done due to risk for dosing error;
Never, because of possible severe hypertension
348
pharm for OB pts PP: what is the second line of med for bleeding after methergine?
hemabate
349
pharm for OB pts PP: what route is hemabate always given? dose? q how many min? max dose?
IM;
Typical dose is 250 mcg;
Can be repeated every 15-30 minutes;
max of 1mg
350
pharm for OB pts PP: if hemabate is given IV what can it cause?
Can cause severe bronchospasm if accidently given IV
351
pharm for OB pts PP: what has been the traditional gold standard to treat maternal hypotension? why preferred over phenyl?
ephedrine;
| Indirect agent thought to cause less of a decrease in uteroplacental blood flow than phenylephrine
352
pharm for OB pts PP: what is max dose of ephedrine?
Max dose of ephedrine is 25 mg every 5 minutes
353
pharm for OB pts PP: what is the benefit of phenyl over ephedrine?
causes less acidosis than previously thought
354
pharm for OB pts PP: which direct alpha antagonist is used for HTN?
hydralazine
355
pharm for OB pts PP, hydralazine: dose q how many min? how long for peak effect?
Typical dose is 5mg IV every five minutes;
| 5min...be patient!
356
pharm for OB pts PP, HTN: what beta blocker with alpha activity can give? dose?
labetalol;
| 5-10mg
357
pharm for OB pts PP, HTN: what is the dose of NTG bolus?
50mcg
358
pharm for OB pts PP, HTN: why avoid Esmolol? nitroprusside?
```
fetal bradycardia;
fetal acidosis (hypoxemia)
```
359
pharm for OB pts PP, HTN: what are the effects of CCB?
Calcium channel blockers: Tocolytic effects
360
pharm for OB pts PP, preterm labor:
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