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Advanced Anesthesia > Obstetrics > Flashcards

Obstetrics Flashcards

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1
Q

The only respiratory parameter that does not increase or decrease during pregnancy ?

A

Vial capacity

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2
Q

Thromboxane A2 levels in preeclampsia?

A

DUE TO DYSFUNCTIONAL ENDOTHELIAL CELLS:

Increased thromboxane A2
+
Decreased prostaglandin I2 (prostacyclin)
=
vasoconstricted state

(Often treated with aspirin bc as a cyclooxygenase inhibitor —> thromboxane production is decreased)

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3
Q

pathogenesis of late decelerations?

A

uteroplacental insufficiency –> decreased oxygen delivery to placenta and fetus –> activation of fetal chemoreceptors –> fetal VAGAL activity stimulated (parasympathetic nervous system)

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4
Q

Ritodrine and terbutaline mechanism of action

A

Tocolytics: beta-2 > beta-1 agonists —> ATP —> cAMP —> DECR calcium —> impaired contractility —> smooth muscle relaxation

Side effects: tachycardia (beta 1 stimulation), hypotension (blood v relaxation), hyperglycemia, hypOkalemia, PULMONARY EDEMA

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5
Q

Late decelerations signify?

A

Uteroplacental insufficiency: gradual decrease of fetal heart rate AFTER peak of uterine contraction

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6
Q

Variable decelerations signify?

A

Cord compression: ABRUPT decrease in fetal heart rate NOT associated with uterine contractions

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7
Q

Early decelerations signify?

A

Fetal head compression: GRADUAL decrease in fetal heart rate that correlates with peak of uterine contraction

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8
Q

What is fetal scalp pH < 7.20 suggests?

A

Fetal acidosis

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9
Q

A negative fetal fibronectin test suggests?

A

Risk of preterm labor < 1% for one week

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10
Q

Most common cause of early post-partum hemorrhage?

A

Uterine stony (BIG/SICK/TIRED uterus)

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11
Q

Normal umbilical artery blood gas?

A

7.25/50/20

20-30-40-50 (Ua O2 - Uv O2 - Uv CO2 - Ua CO2)

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12
Q

Normal umbilical vein blood gas?

A

7.35/40/30

20-30-40-50 (Ua O2 - Uv O2 - Uv CO2 - Ua CO2)

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13
Q

Coagulation factors that DECREASE during pregnancy?

A

Most INCREASE! Fibrinogen nearly doubles.
INCREASED resistance to activated Protein C
INCREASED RBC mass
INCREASED plasma volume

Factors that DECREASE: XI, XIII, ATIII, tPA, Protein S, and platelet count

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14
Q

“tHINGS” that don’t cross the placenta?

A

Heparin
Insulin
Non-depolarizers
Glycopyrrolate
Sux
Phenylephrine

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15
Q

First stage of labor mediated by which dermatomes?

A

T10-L1: paracervical and hypogastric plexus (visceral sensation from uterus and cervix)

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16
Q

Second stage of labor mediated by which dermatomes?

A

T12-L1 (hypogastric plexus) and S2-S4 (pudendal nerve): somatic sensation from perineum and vaginal stretch

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17
Q

Cervical dilation to 10 centimeters is which stage of labor?

A

First stage

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18
Q

10 centimeters to delivery of baby is what stage of labor?

A

Second

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19
Q

Neuroaxial adjunct with kappa opioid agonism and local anesthetic properties?

A

Meperidine: extends duration of analgesia and strengthens degree of sensory/motor blockade

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20
Q

Blood gas in non-pregnant person versus pregnancy?

A

Non-pregnant: 7.4/40/100/24

Pregnant: 7.44/30/107/21

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21
Q

Driver for increased minute ventilation in pregnancy?

A

Progesterone —> TV increased more than RR

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22
Q

closing capacity and FRC in pregnancy?

A

CC>FRC especially in supine position or under GA —> leads to increased atelectasis and decreased PaO2 in a setting of INCREASED O2 consumption —> rapid desaturations

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23
Q

Protective factors against PDPH?

A

Increased age (>60)
Obesity
Men
Saline LOR technique (versus air)

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24
Q

Dermatome coverage needed for cerclage placement?

A

Cervix: T8-S4
Vagina: T10-L1
Perineum: S2-S4

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25
What type of anesthesia preferred if “bulging membranes” during labor?
General
26
Normal p50 for Hb?
27 mmHg
27
Maternal P50 for Hb?
30 mm Hg (right shift)
28
Fetal p50 for hemoglobin?
19-21 mmHg (left shift)
29
After how many weeks in pregnancy does risk of aspiration become significant?
18 weeks
30
Preferred mode of anesthesia for retained placenta?
none to minimal bleeding: IV/sublingual nitroglycerin -OR- regional with minimal sedation hemorrhaging: general anesthesia
31
Mode of anesthesia when uterine inversion is needed?
1st line = low-dose IV/sublingual nitroglycerin volatiles if 1st line fails this is a surgical EMERGENCY - must be manually reversed before cervical ring closes upon uterine fundus
32
Mechanism of increased atrial natriuretic peptide in response to oxytocin?
oxytocin structurally similar to vasopressin --\> at doses \>5 units, urine output is decreased --\> volume overload sensed by atria --\> atrial natriuretic peptide released --\> natriuresis --\> hyponatremia
33
Magnesium competitively inhibits which pain receptor?
NMDA
34
treatment for magnesium toxicity?
calcium
35
APGAR score requiring immediate resuscitation?
0-3
36
APGAR score requiring close observation and more advanced care?
4-7
37
normal APGAR score?
8-10
38
Effect of pregnancy on gastric emptying, peristalsis and intestinal transit?
Gastric emptying: NORMAL during pregnancy, DECR during LABOR ONLY Peristalsis: decreased intestinal transit: decreased (due to increased progesterone and DECR motilin)
39
Preferred first line treatment for acute management of tachyarrhythmias in pregnancy?
Adenosine if vagal maneuvers and carotid massage ineffective. 2nd line: digoxin, verapamil, and beta blockers Very short half-life makes it unlikely to affect fetus
40
Preferred mode of anesthesia for EXIT procedure?
3 options: high dose volatiles (2-3 MAC) lower dose volatiles with nitroglycerin -OR- CSE with nitroglycerin boluses and/or infusion GA has added advantage of fetal anesthesia; but additional meds can be given IM to fetus after partial delivery including fentanyl and relaxants
41
Most common side effects of EXIT procedures?
maternal hypotension and uterine atony
42
Cardiac output changes in 1st, 2nd and 3rd trimester?
1st: HR increases 2nd/3rd: stroke volume increases CO=HR x SV
43
Cause for 150% increase in CO immediately after delivery of baby?
delivery removes vena caval compression by baby and uterine contraction causes autotransfusion of blood
44
CO level at 48 hours postpartum compared to pre-pregnancy?
50% higher
45
CO level at 2 weeks postpartum compared to pre-pregnancy?
10% higher
46
When does CO return to pre-pregnancy levels?
24 weeks postpartum
47
Concentration of volatiles required to decrease myometrial contractility by 50%?
Sevo/des: 0.8-1.7 MAC isoflurane: 2.4 MAC
48
Mainstay treatment of antiphospholipid syndrome?
anticoagulation with aspirin and heparin (or LMWH) treatment should continue for 6 weeks postpartum
49
Mechanism of antiphospholipid syndrome?
Autoantibody inhibits fibrinolytic system leading to complement mediated thrombosis
50
Lab evidence of antiphospholipid syndrome?
elevated aPTT = This does not suggest a bleeding tendency bc NOT due to factor deficiency; This is due to phospholipid-related coagulation alterations. Neuroaxial anesthesia can be done safely.
51
Intrathecal dose of LA used for cerclage placement?
Approximately half the dose used for a cesarean
52
Risk factors for neonatal transmission of genital herpes simplex virus 2?
primary infection active disease at labor/vaginal delivery invasive fetal monitoring \*\*neuroaxial anesthesia is not contraindicated with _recurrent_ maternal HSV2
53
Placental accreta from least to greatest risk?
accreta \< increta \< percreta increta: invades myometrium percreta: invades thru uterine serosa (past myometrium and potentially into other pelvic structures)
54
abnormality in placental accreta?
placenta implants with an absent decidua resulting in abnormal detachment after birth -→ life treatening bleed
55
marginal placenta previa vs. partial placenta previa
marginal: insertion of placenta close to os but does not cover os partial: placenta covers partial but not all of cervical os
56
How does placenta previa increase risk of hemorrhage?
1. uterine incision may cut into anteriorly located placenta 2. the lower uterine segment does not contract as well as normal fundal implantation 3. presence of previa increases risk of accreta
57
Most common cause of prolonged LATENT phase of labor? (\>20 hours in nulliparous, \>14 hours in multiparous)
unripe cervix or false labor
58
2 types of delayed labor during the ACTIVE phase?
1. primary dysfunctional labor: cervix does not dilate at appropriate rate of 1.2-1.5 centimeters per hour 2. secondary arrest of dilation: no cervical dilation x 2 hours \*\*both due to cephalopelvic disproportion
59
cause of dysfunctional labor during active phase?
cephalopelvic disproportion - clearly linked to increased cesarean rate
60
risk factors for uterine rupture?
uterine scar, polyhydramnios, and advanced maternal age
61
formula for uterine blood flow
UBF = systemic vascular resistance/uterine vascular R
62
Why does central venous pressure not increase during pregnancy given the increased blood volume?
The increased blood volume is matched by an increase in venous capacitance.
63
Do anticholinesterase drugs like neostigmine cross the placenta?
Only small amounts cross because quaternary in structure, hydrophilic and ionized Enough to cause fetal bradycardia therefore use neostigmine and atropine for reversal instead of neostigmine and glycopyrrolate
64
umbilical artery blood gas parameters necessary for cerebral palsy
pH\<7 base deficit \> or = 12
65
why is nitrous avoided in pregnancy?
inhibition of methionine synthetase involved in folate metabolism and DNA synthesis
66
Chronic benzodiazapine use in pregnancy associated with?
cleft lip
67
Cocaine use in pregnancy associated with?
growth retardation
68
Tetracycline use in pregnancy associated with?
fetal skeletal malformation and tooth enamel hypoplasia
69
ACE-I use in pregnancy associated with?
fetolethality
70
Warfarin use in pregnancy associated with?
MR and skeletal malformations
71
How do beta-agonist tocolytics cause hypoglycemia in neonates?
raised maternal blood sugar -→ maternal glucose (but not maternal insulin) crosses placenta to fetus -→ fetal pancreas produces insulin -→ after delivery and clamping of umbilical cord, fetal insulin causes hypoglycemia due to sudden absence of maternal glucose transfer
72
intrathecal administration of 2-chlorprocaine not recommended why?
case reports of adhesive arachnoiditis - severe form of inflammation that results in adhesion of nerve roots to one another -→ chronic pain and neuro deficits
73
neuroaxial dermatome coverage needed in cesarean?
T4-S4
74
What does a sinusoidal fetal heart rate pattern indicate?
smooth wave like pattern indicates fetal anemia (or occasionally maternal IV opioids)
75
What does a saltatory fetal heart rate pattern indicate?
excessive alterations in variability indicates acute fetal hypoxia
76
When is fetal heart rate monitoring feasible? When does it become particularly useful?
feasible at 18-20 weeks particularly useful after 25 weeks since fetal heart rate variability is present Normal FHR: 120-160 bpm normal variability: 5-25 bpm
77
Mechanism of bradycardia induced by fetal hypoxemia
Activation of fetal chemoreceptors -→ vagus nerve Direct myocardial depression
78
Autonomic nervous system responsible for fetal heart rate variability?
parasympathetics: matures later in gestation early gestation mediated by sympathetics
79
Effect of epinephrine on epidural lidocaine versus bupivicaine?
epinephrine prolongs DOA of epidural lidocaine little to no effect on DOA of epidural bupivicaine
80
How does serum albumin change in pregnancy?
Decreases due to plasma volume expansion. Most other serum constituents (like transferrin, globulins) increase likely due to hormonal changes during pregnancy.
81
fetal scalp pH suggestive of fetal acidosis and distress?
\<7.2
82
amniotic fluid embolism is akin to \_\_\_\_\_?
severe systemic inflammatory response with (1) severe pulmonary hypertension with RV failure that progresses to (2) LV failure and pulmonary edema treat is supportive with intubation, **vasopressors**, fluids, and blood products
83
A combination of which type of tocolytic in the setting of magnesium sulfate is MOST likely to result in respiratory insufficiency due to muscle weakness?
Calcium channel blockers
84
Diagnostic test of choice for retained epidural catheter?
CT scan MRI with poorer localization secondary to magnetic interference from the catheter tip and possible tissue damage due to heating of wires Fluoroscopy has less resolution
85
Relative contraindication for a labor CSE?
Anticipated difficult airway or non-reassuring fetus because a presence of an UNTESTED catheter which may become critical. Alternative technique: dural puncture epidural, i.e. “dry CSE”
86
VEAL CHOP
variable decels - cord compression early decels - head compression accelerations - OK late decels - placental insufficiency
87
Most common complication with epidural placement in early stage ! of labor?
maternal fever - mechanism unclear but this is not a reason to not place an epidural at this stage
88
Mechanism for increased risk of cholesterol gallstones and cholecystitis during pregnancy?
Progeserone inhibits cholecystokinin release leading to reduced gallbladder emptying
89
How does alkaline phosphatase change in pregnancy?
Isecreted by the placenta and leads to a 2- to 4-fold INCREASE
90
Differences between accreta, increta, and percreta?
accreta: placenta adheres directly to surface of myometrium INcreta: placenta invades INto myometrium Percreta: placenta invades THRU myometrium into serosa
91
When are pregnant multiple sclerosis patients at highest risk of relapse?
up to 3 months post partum relapse rate decreased with each trimester due to increased immunity as normal physiology of pregnancy

Advanced Anesthesia (11 decks)

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