OB: Obstetric Complications Flashcards by Linsley Lloyd

Black, American Indian, and Alaska Native women are _______ times more likely to die from pregnancy related causes than white women.
Black PRMR 40.8/100,000
White PRMR 12.7/100,000

2-3x

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This disparity ____________ with age.

increases

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Black women with a college degree are _____ times more likely to die from pregnancy related causes than their white counterparts.

5.2x

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Pregnancy related deaths – death of a woman during pregnancy or within ____ _____ from the end of pregnancy from a pregnancy complication; chain of events initiated by pregnancy; or the aggravation of a chronic condition by the physiologic effects of pregnancy

one year

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In 2010, 287,000 women died while pregnant or within 42 days of the end of pregnancy
_____ maternal deaths per 100,000 live births

210

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1 in ____ lifetime risk of maternal death for each girl

180

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More than 99% of maternal deaths occur in developing countries, 85% in either sub-Saharan Africa or South Asia
In sub-Saharan Africa lifetime risk of maternal death is I in ____

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Most Common Causes of Maternal Mortality

Developed world

Hypertensive disorders of pregnancy
Embolic disorders
Hemorrhage

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Most Common Causes of Maternal Mortality

Globally

Hemorrhage
Hypertensive disorders of pregnancy
Sepsis

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Other Causes of Global Maternal Mortality

Anemia
Obstructed labor
HIV/AIDS
Unsafe abortion
Early marriage
High parity birth
Advanced maternal age

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Preterm Delivery

Delivery prior to ____ ____ gestation

37 weeks

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Preterm Delivery

___-___% of all pregnancies in the US, 5-9% in other developed countries

12-13

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Preterm Delivery

Responsible for ___-___% of all neonatal deaths and significant neonatal morbidity

75-80

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Preterm Delivery

Approximately 90% of preterm births occur between _____ and ______ weeks

32 and 36 6/7

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Preterm Delivery

______ is less common, but _____ is a greater concern in this age range

Mortality
morbidity

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Risks of Preterm Labor

Demographic Characteristics

Non-Caucasian race
Extremes of age (<17 or >35)
Low socioeconomic status
Low pre-pregnancy BMI
History of preterm delivery
Interpregnancy interval <6 months
Abnormal uterine anatomy
Trauma
Abdominal surgery during pregnancy

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Risks of Preterm Labor

Obstetric Factors

Vaginal bleeding
Infection
Short cervical length
Multiple gestation
Assisted reproductive technologies
Preterm premature rupture of membranes
Polyhydramnios

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Prevention of Preterm Labor (4)

Cervical cerclage
Prophylactic antibiotics??
Prophylactic beta agonists??
Progesterone??

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Therapy for Prevention of Preterm Labor

Corticosteroids

Betamethasone
Dexamethasone

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Therapy for Prevention of Preterm Labor

Tocolysis

Magnesium sulfate
Beta agonists (Terbutaline)

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Magnesium
May ____ _____ contractions, even at toxic levels
Normal serum Mg is ___-___ mg/dL
Therapeutic ___-___ mg/dL
10-12 mg/dL patellar tendon reflex eliminated
>12 mg/dL respiratory depression
18 mg/dL apnea
25 mg/dL cardiac arrest

not stop
1.8-3
4-8

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Side effects - Dose dependent
Skeletal muscle weakness, subclinical neuromuscular blockade (depolarizing and nondepolarizing potentiated by Mg). A priming or defasciculating dose _______________________
Vascular dilation – antagonizes the vasoconstrictive effect of alpha agonists so ephedrine and phenylephrine may be _____ ______
Cutaneous vasodilation (flushing)
Headache and dizziness
Depression of deep tendon reflexes
Respiratory depression
Ecg changes

may cause profound block
less effective

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Beta 2 receptor system stimulates smooth muscle _______ (including ______ of the uterus)
B2 also increases ______ production

relaxation
relaxation
progesterone

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No pure B2 agonists, B1 increases ____ ____, myocardial contractility, and myocardial ____ _____

Maternal side effects
Cereberal vasospasm
Chest pain or tightness
Glucose intolerance
Hypokalemia
Illeus
Myocardial ischemia
Nausea
Palpitations
Pulmonary edema
Restlessness
Tremor
Ventricular arrhythmias

heart rate
O2 demand

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______ can antagonize hypoxic pulmonary vasoconstriction through B2 mediated vasodilation can decrease maternal oxygen tension SEs: fetal tach, neonatal hypoglycemia

Turbutaline

Incidence of pregnancy related _______ events is 1-1.7 events per 1,000 pregnancies

thromboembolic

Thromboembolism - Five times greater odds during pregnancy and ___ times greater in postpartum period than the nonpregnant patient

Two most important modifiable risk factors are antenatal:

immobility and obesity

Deep Vein Thrombosis Presentation mimics ______ pregnancy symptoms _____ _____ edema Pain

normal Lower leg

DVT - Diagnosis __-____ elevated in normal pregnancy Ultrasound

D-dimer

Pulmonary Embolism One or more DVT symptoms with ____ or _____ findings

pulmonary or CV

Treatment of Thromboembolic Events - Anticoagulation

Low-molecular weight heparin Unfractionated heparin

Treatment of Thromboembolic Events - Implications Neuraxial analgesia –

epidural or spinal hematoma

Treatment of Thromboembolic Events - Implications General -

risk of airway trauma/bleeding

Venous Air Embolism ______ during cesarean delivery

“Common”

Venous Air Embolism Most volumes are small, volumes greater than _______ mL may be lethal.

200-300

Venous Air Embolism Reporting incidence varies Precordial doppler/______ _____ 11/42 (26%) Increase in the expired _____ 0.1% (=0.25-1.0 mL/kg) 29/30

Transthoracic Echo nitrogen

Venous Air Embolism Consider for intraoperative chest pain, dyspnea, sudden hypo_____, hypo_____, or ______

hypoxemia hypotension arrhythmia

Amniotic Fluid Embolism Diagnosis of ______________

exclusion

Amniotic Fluid Embolism Incidence is ______ to _____ UK 0.8-2:100,000 Australia 3.3:100,000 US 7.7:100,000

difficult determine

Amniotic Fluid Embolism no _____ _____

No confirmatory tests

Amniotic Fluid Embolism ____ exact course or initial symptoms

AFE Differential Diagnosis Nonobstetric

AMI PE Aspiration Sepsis Anaphylaxis VAE

AFE Differential Diagnosis Obstetric

Abruption Eclampsia Uterine rupture or laceration Uterine atony

AFE Differential Diagnosis Anesthetic

Total spinal Local anesthetic toxicity Medication error

AFE Management - airway (2)

100% O2 Intubate

AFE Management - CV support _____ _____ if indicated _____ uterine displacement Fluids and Vasopressors Large bore IV access Consider invasive pressure monitoring

Chest compressions Left

AFE Management - Fetus (2)

monitor fetal wellbeing expedite delivery

AFE Management - Hemostatic supprt Hemorrhage/____ _____ protocol Send labs for coags and electrolytes ____thermia

massive transfusion Normo

AFE Management - Post-resuscitation care

ICU

Prolapsed Umbilical Cord Umbilical cord protrudes ahead of fetus __________________ is the problem

cord compression

Hemorrhage Most common cause of maternal mortality worldwide – ____%

25%

Hemorrhage ______% of pregnancy related deaths in the US

12.5%

Hemorrhage Majority of hemorrhage-related adverse outcomes are considered ______. Failure to recognize _____ _____ Failure to accurately estimate ____ ____ Failure to initiate treatment in a ____ ____

preventable risk factors blood loss timely fashion

Mechanisms of Hemostasis Uterine _____ (due to ______) is the primary mechanism for controlling blood loss

contraction oxytocin

Mech of Hemostasis Uterine contraction constricts ____ ____ & _____ ____

spiral arteries and placental veins

Mech of Hemostasis After disruption of vascular integrity coagulation mechanisms:

1. Platelet aggregation and plug formation 2. Local vasoconstriction 3. Clot polymerization 4. Fibrous tissue fortification of the clot

Hemorrhage Tachycardia and hypotension are ____ signs of hemorrhage, especially in healthy young patients

LATE

Hemorrhage Estimation of blood loss is ____ accurate with larger volumes of loss

less

Placenta Previa When the placenta implants ____/___ the cervix Incidence 4:1,000 Antepartum _____

near/on hemorrhage

Placenta Previa Be prepared for hemorrhage, even in ______/______ cesarean delivery

elective/non-urgent

Placenta Previa Increased risk of placenta _____

accreta

Placenta Previa ______ anesthesia associated with more stable hemodynamics and lower transfusion rates than ______

Epidural general

Placenta Previa Patients with active bleeding

- Urgent/emergent presentation - May keep bleeding until delivery/placenta is removed - GETA/RSI - Induction agent depend on hemodynamic stability - Maintenance – may use 50% Nitrous to limit volatile agents

Placental Abruption When the placenta _____ from the _____ prior to delivery

separates from the uterus

Placental Abruption can be _____ or _____

complete or partial

Placental Abruption ___-___% of all pregnancies

0.4-1.0

Placental Abruption Incidence is _____, particularly among African American women in the US cause is not well understood

increasing

Placental Abruption Patients hospitalized for acute and chronic respiratory disease at _____ ______, unknown reasons

increased risk

Placental Abruption Anesthesia Management - Vaginal Delivery ______ analgesia Treat ______ ______ can increase risk to extend abruption Question further hemorrhage Consider IV PCA

Neuraxial hypovolemia Sympathectomy

Placental Abruption Anesthesia Management - Cesarean Delivery General is ____ in most urgent cases, otherwise _____ is may be used in normal coagulation status and volume Aggressive volume resuscitation is _____ Uterine atony requires uterotonic drugs

preferred neuraxial critical

Uterine Rupture Previous _____ _____ (c-section, myomectomy)

uterine surgery

Uterine Rupture Emergency ______

laparotomy

Uterine Rupture _____ compromise is likely

fetal

Uterine Rupture Usually general except some stable patients with _____ _______ ______

preexisting labor epidural

Uterine Rupture Aggressive _____/______ may be necessary

volume/transfusion

Uterine Rupture _____ monitoring?

Invasive

Postpartum Hemorrhage Most common definition is >_____cc vaginal delivery, >_____cc c-section

500 1000

Postpartum Hemorrhage Only slightly ____ than averages

higher

Postpartum Hemorrhage Common causes (5)

Uterine atony Retained placenta Genital trauma Uterine Inversion Placenta Accreta

Uterine Atony ____ _____ cause of severe postpartum hemorrhage (80%)

Most common

Uterine Atony Prophylaxis - ACOG recommends prophylactic administration of uterotonic agents to prevent uterine atony - Uterine _____ & _____ administration decreases blood loss and transfusion requirements - ______ – first line drug for prophylaxis and treatment - Side effects – tachycardia, hypotension, ____ ____

massage and oxytocin Oxytocin myocardial ischemia

Uterine Atony Treatment ____ ____ – fungus - methergine (Unstable unless refrigerated, Rapid onset IM) _______ - hemobate

Ergot alkaloids Prostaglandins

Genital Trauma _____ & ______ of the perineum, vagina, and cervix

Lacerations and hematomas

Genital Trauma May need ____ or ______ for repair

anesthesia or sedation

Genital Trauma Vaginal/vulvar ______

hematomas

Genital Trauma least common, concealed bleeding

retroperitoneal hematomas

Retained Placenta Failure to completely ____ ____

deliver placenta

Retained Placenta Anesthetic requirements vary based on _____ _____

obstetric needs

Retained Placenta Neuraxial?

Retained Placenta May require uterine relaxation

High dose volatile anesthetics Nitroglycerine - (Rapid onset of smooth muscle relaxation, Short half life, Different studies have found success with varying dosages 50-100 mcg, to 500 mcg)

Uterine Inversion is ____

rare

Uterine Inversion Severe post partum ______

hemorrhage

Uterine Inversion May have concurrent _____ _____ _____ bradycardia

vagal reflex mediated

Uterine Inversion May need ______ to relax uterus

nitroglycerine - Larger (200-250 mcg) may be required

Uterine Inversion Support circulation with ____ ____

IV fluids

Uterine Inversion _____ may be necessary

Uterine Inversion Once uterus is replaced, a ____ ____ _____ uterus is desired

firm well contracted

Placenta Accreta Placenta that invades the uterine wall and is ______ from it.

inseparable

Placenta Accreta ____ ____ – adherence of the basal plate of the placenta to the myometrium

Accreta vera

Placenta Accreta ____ – chorionic villi invade myometrium

Increta

Placenta Accreta _____ – invasion through the myometrium, into serosa and maybe other organs (usually bladder)

Percreta

Placenta Accreta Management - Transfer to facility with adequate blood banking if necessary - _____ c-section - Internal iliac artery balloon catheters? - Blood loss exceeds _____cc in ____ of cases, 5000cc in 15% and 10,000cc in 6.5%

Planned 2000 2/3

DIC Generalized ______ of the clotting system

activation

DIC Large portion of vascular system damage or _____ ______ in general circulation

thromboplastic materials

DIC usually d/t:

Retention of dead fetus Placental abruption Amniotic fluid embolism

DIC Accompanied by circulatory shock, renal failure, uncontrolled bleeding due to ______ of ______ ______

consumption of clotting factors

OB: Obstetric Complications Flashcards

(107 cards)