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AS - N934 Advanced Principles II > Obstetrics/OBGYN > Flashcards

Obstetrics/OBGYN Flashcards

(63 cards)

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1
Q

Cardiovascular Changes w/ Pregnancy

A 
↑HR 20-30% peaks at 32 weeks
↑CO 40% returns to baseline w/in 14 days
Ventricular walls thicken
↑EDV
Dilutional anemia ↑↑plasma volume ↑RBCs
↓SVR → venous pooling & ↓diastolic BP to compensate BP w/ hypervolemia & ↑blood volume
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2
Q

Aortocaval Compression

A

Supine position → HoTN d/t aorta & vena cava compression from gravid uterus
Treatment = L uterine displacement

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3
Q

Hematological Changes w/ Pregnancy

A

Hypercoagulable ↑clotting factors VII-IX & fibrinogen
↑risk thromboembolic events (leading cause maternal mortality)
↓platelet count minimal
↑WBC count
Dilutional anemia

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4
Q

Airway Changes w/ Pregnancy

A

Airway swelling during labor
Capillary engorgement → narrowed glottic opening (use smaller ETT 6.0 or 6.5 cuffed), oral & nasal pharynx edema (avoid nasal intubation), & laryngeal edema
Consider short laryngoscope handle

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5
Q

Respiratory Changes w/ Pregnancy

A

↑oxygen consumption
↑minute ventilation ↑↑VT ↑RR (tachypnea not normal)
↓PaCO2 minimal w/ compensatory ↓HCO3¯
Diaphragm shifts upward ↓FRC
Rapid desaturation in apneic patient (ensure adequate pre-oxygenation)

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6
Q

Neurological Changes w/ Pregnancy

A

↑sensitivity to anesthetic gases & LAs
↑block height d/t engorged epidural veins that compress the dura & exaggerate the LA spread
↑intra-abdominal pressure ↓epidural & subarachnoid spaces

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7
Q

Gastrointestinal Changes w/ Pregnancy

A

↑risk regurgitation & aspiration
↑gastrin levels
Mechanical obstruction d/t upward displacement
Labor further ↓gastric emptying

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8
Q

What medications to administer prior to C-section to ↓aspiration risk?

A
  1. Bicitra (non-particulate antacid)
  2. Famotidine (Pepcid) H2 receptor antagonist
  3. Metoclopramide (Reglan) prokinetic that neutralizes stomach acid
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9
Q

Hepatic Changes w/ Pregnancy

A

↓serum albumin

↑free fraction highly protein-bound drugs

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10
Q

Renal Changes w/ Pregnancy

A

↑GFR
↓BUN & creatinine
Glucose excreted via urine d/t ↑GFR & ↓renal absorption
↑protein excretion

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11
Q

Uterine Blood Flow

A

Term ↑800mL/min
Receives 10% CO
- 150mL/min supplies nutrients to the myometrium
- 100mL/min flow to the decidua basalis (maternal portion placenta)
Fetus sends O2 poor blood to the placenta AVA
Placenta exchanges nutrients, respiratory gases, & waste
O2 & CO2 exchange are perfusion limited

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12
Q

How do medications transfer across the placenta? What is able to cross?

A

Transfer via diffusion

Other factors:

  • Non-ionized
  • Small (molecular weight)
  • Dependent on concentration gradient & lipid solubility
  • Protein binding
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13
Q

How much fetal CO returns directly back to the placenta? How?

A

1/5 fetal CO

Shunts flows from PFO & PDA

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14
Q

What affects drug accumulation w/in the fetus?

A

Acid-base status

Ion trapping

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15
Q

What decreases the fetal drug effects?

A

Dilution w/ intervillous blood
Redistribution w/in the fetus
1st pass liver effect
↑maternal hepatic enzymes ↓serum drug levels

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16
Q

Labor & Delivery

STAGE I

A

Cervix effacement & dilation
Latent - labor onset to rapid cervix dilation
Active - cervix dilation 2cm to full dilation at 10cm

Non-localized aching or cramping T10-12 & L1

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17
Q

Labor & Delivery

STAGE II

A

Cervix dilation 10cm to fetus delivery

Presenting part descends into the pelvis → perineal stretching S2-4

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18
Q

Labor & Delivery

STAGE III

A

Placenta delivery

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19
Q

Fetal Heart Rate

Variability

A

Indicates fetal well-being & O2 reserve
Hypoxia → CNS depression ↓HR
Accelerations are reactive - indicate fetal movement & adequate oxygenation

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20
Q

Fetal Heart Rate

Early Decelerations

A

Occur w/ uterine contractions
Consistent
↓fetal HR approximately 20bpm

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21
Q

Fetal Heart Rate

Variable Decelerations

A

Abrupt ↓HR irrespective to contractions

Baroreflex-mediated response to umbilical cord compression

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22
Q

Fetal Heart Rate

Late Decelerations

A

NON-REASSURING
Lowest deceleration point occurs after peak contraction
Represent uteroplacental insufficiency

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23
Q

Fetal Heart Rate

Category I

A

Normal baseline HR & moderate variability w/ NO variable or late decels

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24
Q

Fetal Heart Rate

Category II

A

All tracings not included in I or III
Do not indicate acid-base imbalance
Warrant continued observation

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25
Fetal Heart Rate | Category III
Fetal bradycardia & absent variability w/ variable or late decels Warrants prompt intervention
26
Labor analgesia dermatome level goal:
T10-L1
27
Caesarean section dermatome level goal:
T4-6 to provide adequate analgesia Epidural 10-15mL
28
Combined Spinal/Epidural (CSE)
Place spinal 1st then place the epidural one level above OR Needle through needle technique
29
CSE Advantages
Lower spinal dose | Ability to re-dose w/ epidural catheter
30
CSE Disadvantages
Potential lower block height | Surgical start delay
31
Neuraxial Opioid Side Effects
Respiratory depression Itching Urinary retention N/V Opioids have ceiling effect beyond conventional doses
32
Caesarean Section Indications
``` Cephalopelvic disproportion Non-reassuring fetal status (ex: late decels) Failure to progress (dilation arrest) Malpresentation Prematurity Previous C/S or uterine surgery ```
33
Neuraxial Advantages over General
↓mortality risk d/t failed intubation ↓aspiration risk Improved neonatal outcomes Mother able to participate in birth
34
When to utilize L uterine displacement?
Regardless the anesthetic technique to prevent aorta compression → late decels
35
Spinal Advantages
Simple to perform Rapid onset Reliable block Less toxic 0.75% hyperbaric Bupivacaine DOA 90-120min
36
Spinal Disadvantages
Fixed DOA (single shot) HoTN Inadequate coverage
37
Epidural Advantages
Less abrupt blood pressure changes | Able to re-dose catheter
38
Epidural Disadvantages
Slower onset | Higher LA dose required
39
General Anesthesia Indications
Patient refusal Coagulopathy Spinal or epidural does not provide adequate surgical coverage Urgent delivery
40
OB Complications | Post-Partum Hemorrhage
EBL > - Vaginal delivery 500mL - C-section 1,000mL
41
Post-Partum Hemorrhage | Causes & Risk Factors
``` Uterine atony 80% Uterine abnormalities Placental retention Lacerations Uterine inversion Coagulation abnormalities ``` Multiparity (previous pregnancy) Prolonged oxytocin infusion Polyhydramnios Multiple gestation
42
Post-Partum Hemorrhage | Treatment
Uterotonics stimulate uterine contractions - Oxytocin, Methergine, PGEs (Carboprost/Hemabate), and/or Misoprostal Antifibrinolytics TXA MTP and/or cell salvage Surgical intervention - Retained placenta, NTG, hysterectomy Intrauterine balloon
43
Oxytocin
Synthetic Pitocin lowers depolarization threshold Ca2+ channel activation & ↑prostaglandin production 20-40 units
44
Methylergonovine (Methergine)
Ergot alkaloid 0.2mg IM repeat Q15-20min Max dose 0.8mg NEVER IV BOLUS → profound HTN & cerebral hemorrhage Contraindicated in pre-existing HTN, PVD, & ischemic heart disease
45
Prostaglandins | Carboprost (Hemabate)
↑myometrial Ca2+ levels & MLCK activity 250mcg IM or direct into myometrium repeat Q15-30min Max dose 2mg Reactive airway disease → bronchospasm, VaQ mismatch, & hypoxemia
46
Misoprostol
Prostaglandin E1 analog ↑myometrial Ca2+ levels & MLCK activity 800-1,000mcg sublingual or buccal Okay to admin to patients w/ reactive airway disease or pulmonary HTN
47
Nitroglycerin
Nitric oxide donors ↑cyclic guanosine monophosphate Inactivates MLCK causing smooth muscle relaxation Administered as muscle relaxant to allow surgeon to remove retained placenta ↑bleeding
48
OB Complications | Preeclampsia
Pregnancy-specific multisystem disorder Etiology not understood - failure normal angiogenesis resulting in ↓placental perfusion ↑vascular tone & sensitivity to catecholamines Pronounced upper airway edema during labor
49
Preeclampsia S/S
``` HTN > 140/90 Proteinuria Thrombocytopenia < 100,000 Impaired liver function & severe RUQ pain Renal insufficiency Cerebral or visual disturbances CNS effects - headache, hyperexcitability, & hyperreflexia Hepatocellular necrosis ```
50
Preeclampsia Treatment
``` Avoid uteroplacental hypoperfusion Magnesium sulfate (tocolytic) ↓seizure incidence, venous dilation, ↓uterine activity HTN management Only way to end disease process = delivery ```
51
OB Complications | HELLP
Preeclampsia complication Hemolysis, elevated liver enzymes, & low platelet count Associated w/ progressive & sudden deterioration in maternal & fetal condition
52
HELLP S/S
HTN Proteinuria N/V
53
OB Complications | Obesity
> 20% pregnancies complicated d/t obesity ↑risk HTN, diabetes, & complicated labor → fetal macrosomia (LGA), failed induction/progression, difficult or failed neuraxial, prolonged procedures, & infectious complications
54
OB Complications | Placenta Previa
``` Abnormal placental implantation Placenta implants on lower uterine segment & covers the opening to the cervix 1% incidence Painless vaginal bleeding - Hemodynamically significant blood loss - ↑risk postpartum bleeding C-section indicated ```
55
OB Complications | Placenta Accreta
Placenta normally implants into the endometrium, but placenta accreta implants into the myometrium Placenta increta describes growth through the myometrium & into surrounding organs Associated w/ massive hemorrhage - uterine artery embolization & Caesarean hysterectomy
56
OB Complications | Placenta Abruption
Placenta separates from the uterus during delivery More common in women w/ HTN & PEC Open venous sinuses allows amniotic fluid to enter circulation ↑DIC incidence
57
Placenta Abruption S/S
``` Hemorrhage Painful vaginal bleeding Uterine irritability Abdominal pain Fetal hypoperfusion & distress ```
58
OB Complications | Amniotic Fluid Embolism
Rare event Potential to occur during labor (vaginal delivery or C-section) Occasionally associated w/ placenta abruption
59
Amniotic Fluid Embolism | S/S
``` Anxiety Dyspnea Hypoxia HoTN Cardiovascular collapse Coagulopathy ```
60
Amniotic Fluid Embolism | Treatment
``` Supportive AOK - Atropine - Ondansetron - Ketorolac ```
61
OB Complications | Prematurity
Labor & delivery before 37 weeks gestation Birth weight < 1,500g associated w/ long-term complications (respiratory distress syndrome, intracranial hemorrhage, & hyperbilirubinemia)
62
Non-Obstetric Surgeries in Pregnant Women
``` 1-2% pregnant women require non-OB surgeries Most common = cerclage 2nd lap chole Avoid HoTN & maintain uterine perfusion Prevent premature labor Avoid surgeries in 1st trimester ```
63
APGAR
8-10 normal 4-7 moderate distress or impairment 0-3 immediate resuscitation

AS - N934 Advanced Principles II (18 decks)

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