Obstetric Anesthesia Part 2: Hertz Flashcards by Cindy Ehret

What are considered complicated pregnancies? (6)

Preterm labor
Premature rupture of membranes (PROM)
Chorioamnionitis
Umbilical cord prolapse
Amniotic fluid embolism
Partum hemorrhages

How well did you know this?

Not at all

Perfectly

What defines premature labor?

Labor that occurs between 20-37 weeks gestation

Note: 8% of deliveries

How well did you know this?

Not at all

Perfectly

What are the contributing factors to premature labor? (7)

Extremes of age
Inadequate prenatal care
Unusual body habitus
Increased physical activity
Infections
Prior preterm labor
Multiple gestations

How well did you know this?

Not at all

Perfectly

Preterm infants under ______ weeks and weighing < ______grams have more complications.

30 weeks

1500 grams

How well did you know this?

Not at all

Perfectly

What are breech premis at increased risk of?

Hypoxia and asphyxia

Note: picture of breeched baby.

How well did you know this?

Not at all

Perfectly

What are complications relating to premature infants? (3)

Inadequate surfactant before 35 weeks
Soft, poorly calcified cranium predisposes to hemorrhage
Many premature fetuses are in breech position

How well did you know this?

Not at all

Perfectly

What is premature rupture of membranes (PROM)?

Leakage of amniotic fluid before onset of labor

How well did you know this?

Not at all

Perfectly

What does the combination of PROM and preterm labor increase the risk of?

umbilical cord compression–>fetal hypoxemia

How well did you know this?

Not at all

Perfectly

What are the predisposing factors causing the premature rupture of membranes? (6)

Short cervix
Hx of PROM or preterm labor
Infection
Multiple gestations (twins, triplets)
Polyhydramnios (too much amniotic fluid)
Smoking

How well did you know this?

Not at all

Perfectly

What occurs within 24 hrs in 90% of PROM patients?

spontaneous labor

How well did you know this?

Not at all

Perfectly

When is delivery indicated for PROM patients?

What drugs are indicated?

After 34 weeks of gestation

Otherwise, antibiotics and tocolytics given for 5-7 days

How well did you know this?

Not at all

Perfectly

What is chorioamnionitis?

Infection of the chorionic and amnionic membranes which may involve the placenta, uterus, and umbilical cord.

How well did you know this?

Not at all

Perfectly

What are the maternal complications from chorioamnionitis? (4)

Dysfunctional labor–not contracting well
Intraabdominal infection
Septicemia
Postpartum hemorrhage

How well did you know this?

Not at all

Perfectly

What are the fetal complications of chorioamnionitis? (3)

Acidosis
Hypoxia
Septicemia

How well did you know this?

Not at all

Perfectly

What are the signs of chorioamnionitis? (4)

Fever > 38ºC
Maternal AND fetal tachycardia
Foul smelling fluid
Uterine tenderness

How well did you know this?

Not at all

Perfectly

When is regional safe for a pt with chorioamnionitis? (3)

No signs of septicemia, thrombocytopenia, or coagulopathy.

Note: Pt will be on antibiotic therapy.

How well did you know this?

Not at all

Perfectly

What is depicted?

umbilical cord prolapse

How well did you know this?

Not at all

Perfectly

What are predisposing factors for this to occur? (5)

Excessive cord length
Baby in poor position
Low birth weight
Parity (births) > 5
Rupture of membranes

How well did you know this?

Not at all

Perfectly

How is this diagnosed? (3)

Sudden fetal bradycardia
Profound decelerations
Confirmation by doctor

How well did you know this?

Not at all

Perfectly

What is the treatment for this? (2)

Immediate steep trendelenburg or knees to chest
Push fetal part back into pelvis until stat c-section under general anesthesia

How well did you know this?

Not at all

Perfectly

What is amniotic fluid embolism?

The entry of amniotic fluid into the mom’s circulation which occcurs through any break in uteroplacental membranes.

How well did you know this?

Not at all

Perfectly

What is the incidence and mortality rate of amniotic fluid embolism?

low incidence

high mortality rate

How well did you know this?

Not at all

Perfectly

What does amniotic fluid contain? (3)

fetal debris
leukotrienes
prostaglandins

How well did you know this?

Not at all

Perfectly

When is amniotic fluid embolism likely to occur? (4)

Labor
Delivery
C-section
Postpartum

Note: 50% of mortality in the 1st hour.

How well did you know this?

Not at all

Perfectly

What is the classic triad of symptoms of amniotic fluid embolism?

* Hypoxemia * Hypotension * Coagulopathy

What are other symptoms of amniotic fluid embolism? (6)

Pulmonary edema Cyanosis CV arrest DIC Fetal distress Seizures

What are 3 main characteristics that embody amniotic fluid embolism?

Pulmonary embolism DIC Atony of uterus

How do you treat amniotic fluid embolism? (2)

Aggressive CPR in supine position (do not tilt uterus) Immediate c-section because quick delivery is better for baby and mom

What is placenta previa?

The placenta is abnormally placed and covers the cervix.

Identify the differing placenta previa categories.

List the type of previa that occurs from most to least frequently.

Low-lying or marginal (46%) Complete (37%) Partial (27%)

What are risk factor of placenta previa? (3)

Scarring of uterus from surgeries, pregnancies, ect Multiple gestations Abnormal uterus

What are the symptoms of placenta previa? (2)

PAINLESS vaginal bleeding Episodic bleeding but severe hemorrhage can occur at any time

What is the management for placenta previa?

Less than 37 weeks, bedrest After 37 weeks, c-section

Pts with a low-lying placenta must have a c-section. True or false?

False May deliver vaginally if bleeding is mild.

All patients wiht vaginal bleeding are assumed to have placenta previa until proven otherwise. True or false?

True U/S can localize placenta.

What is anesthesia type for unstable placenta previa pt\>

Stat c-section with general anesthesia

What is needed for anesthesia for placenta previa pt?

Regional is considered in fluid loaded 2 large IVs 2 crossmatched blood units Central line may be good option for rapid transfusion

What is depicted?

Placental abruption aka detachment

When does separation of the placenta normal occur with placenta abruption?

after 20 weeks

What is the danger of placental abruption?

Loss of area for maternal-fetal gas exchange leading to fetal distress

What is the most common cause of intrapartum fetal death?

placental abruption

What are risk factors of placental abruption? (7)

HTN Trauma Short umbilical cord Multiple gestations ROM Drugs Abnormal uterus

What are the symptoms of placental abruption? (4)

Painful bleeding Uterine tenderness Uterine activity increased HTN is common, DIC possible

How is placenta **abruption** diagnosed? (2)

Ultrasound Amniotic fluid is port wine colored

How is mild to moderate abruption treated?

Hospitalized If \> 37 weeks and no fetal distress, vaginal delivery If fetal distress, c-section

What lab value will change as a result of mild to moderate abruption?

decreased fibrinogen, 150-250 mg/dL

What occurs to labs with severe abruption? (4)

Coagulopathy in 10% of cases Fibrinogen \< 150 due to active plasminogen Platelets reduced Factors 5 and 7 reduced

What are anesthetic considerations for severe abruption? (4)

C-section preferred to prevent further abruption Aggressive fluid resuscitation to anticipate high blood loss Vaginal bleeding may not reflect actual bleeding! General preferred to treat hypovolemia

What is the incidence of uterine rupture and the causes? (5)

Rare * Scar from previous surgery. Vertical scars bleed more. * Forceps * Prolonged labor * Strong contractions * Large, thin, weak uterus

What are the signs of uterine rupture? (5)

Fetal distress is most reliable sign Frank hemorrhage Cessation of labor, ineffective contractions Abdominal pain that breaks through epidural Constant pain with NO RELIEF BETWEEN CTX

How do you treat uterine rupture? (3)

Control bleeding by repairing arteries, etc Volume rescuscitation Immediate laparotomy under GETA

What situation will present with abrupt onset of continuous abdominal pain and hypotension even with an epidural?

uterine rupture

What occurs with a retained placenta?

The uterus cannot contract properly and continues to bleed.

Nitroglycerine must not be used when there is a retained placenta. True or false?

False, may be useful in relaxing the uterus.

What is placenta accreta?

abnormally adherent placenta

Label

List occurrence of placenta accreta from most to least.

Accreta (78%) Increta (17%) Percreta (5%)

What is the adherence to myometrium without invasion of or passage through the uterine muscle?

placenta accreta

What is the placental invasion of the myometrium?

increta

What is the invasion of the uterine serosa or other pelvic structures?

percreta, which can also invade the bladder and bowel

What are the risk factors for placenta accreta? (2)

Hx of placenta previa Previous c-section

What is the treatment for placenta accreta?

uterine curretage, then oversewing the bleeding placenta bed but not usually successful most cases require postpartum hysterectomy

What is the anesthetic treatment for placenta accreta? (3)

c/s or lap stat under general blood rescusitate coagulopathy correction

What is the major cause of postpartum hemorrhage?

uterine atony, which is usually accompanied by retained placenta

What is the treatment for uterine atony? (3)

Oxytocin Metherigine (methylergonovine maleate) Carboprost, Hemabate (Prostaglandin F2Alpha )

Where does oxytocin have an effect?

Uterus contractions Mammary glands stimulates contraction of myoepithelial cells for milking Smooth muscle when given in large doses resulting in **decreased BP**

What is the postpartum dose of oxytocin?

20 units in 1000ml LR Infusion: 20-40 mU/min

What are the side effects of oxytocin? (2)

HYPOTENSION N/V

What is methylergonovine maleate (Methergine)? (3 points)

Acts directly on smooth muscle of the uterus via alpha receptors Increases tone, rate of contractions Raises BP and CVP

What is the dosage of methergonovine maleate (Methergine)?

IM: 0.2 mg or IV: 0.02 mg increments

What should you consider when giving methylergonovine maleate (Methergine)? (3)

Use cautiously in pts with HTN or cardiac disease **Caution in ASTHMA pts!** May produce severe HTN, CVAs and retinal detachment

What is prostaglandine F2alpha (Carboprost, Hemabate)?

Synthetic prostaglandin Stimulates smooth muscle for contracting the uterus

What is the dose of Carbaprost, Hemabate?

IM: 250 mcg q 15-90 min as needed Max dose: 2 mg

What is a contraindication of prostaglandin F2alpha (Carbaprost, Hemabate)?

ASTHMA

What drugs do you administer for uterine inversion?

NTG Sevo Helps relax the uterus to put things back inside.

What causes partum hemorrhages? (6)

* Placenta previa * Placental abruption * Uterine rupture * Placenta retained * Placenta accreta * Uterine atony

Do the following cause pain? placenta previa placental abruption uterine rupture retained placenta placenta accreta uterine atony

**The only ones that cause pain are:** * **Placental abruption** * **Uterine rupture**

What can result in potentially massive blood loss?

Placenta previa Placenta accreta

What may conceal bleeding?

Placental abruption Uterine rupture

In what situation may the FHR disappear?

Uterine rupture

What are causes of hemorrhages: antepartum peripartum postpartum?

Antepartum--placenta previa, abruption PA Peripartum--uterine rupture U Post partum--placeneta accreta, uterine atony PU