Week 6 OB Anesthesia Part 2 Flashcards
(90 cards)
1
Q
Changes to ACLS on a patient in the 3rd trimester?
A
- Compressions 2-3 cm higher on sterum
- Manual L uterine displacement (Left & up)
- Standard ACLS drugs
- ~ 5 min to save baby and mom
2
Q
What is important to know about a Perimortem C-section during a cardiac arrest?
4
A
- ~ 5 min to save mom/baby
- Is the fetus viable (24 weeks)
- Fundus @ umbilicus = ~24 weeks
- Incision is from Xiphoid increase caudal
3
Q
What is considered PPH after vaginal/c-section delivery?
A
- Vaginal: >500mL
- C-section: >1000mL
4
Q
What are the 4 causes (T’s) of PPH?
A
- Thrombin (bleeding d/o, pre-eclampsia)
- Tissue (placenta retained)
- Tone (uterine tone)
- Trauma (C/S, episotomy, >4kg baby)
5
Q
1st line drug for uterine atony?
A
Oxytocin
6
Q
Side-effects of oxytocin?
A
- Tachycardia
- HoTN
- Myocardial ischemia
- DEAD (rare)
7
Q
Dilution of Oxytocin?
A
20 units/1L
or
30 units/500mL
8
Q
Dose of Oxytocin?
A
Bolus: 1000mL/hr for 30 min = 10 units
Maintenance: 125mL/hr for 3.5 hrs = 10 units
OR
10 units IM
9
Q
Relative
Contraindications for Methergine (Methylergometrine)
4
A
- HTN
- Preeclampsia
- PVD
- Ischemic heart disease
10
Q
Important note about stability regarding Methergine (Methylergometrine)?
A
Unstable unless refrigerated
11
Q
You’re adminstering Methergine to produce contractions, which route will you administer and why?
A
IM
- IV not recommended
- Causes HTN
12
Q
What is the treatment for ergot related HTN/vasoconstriction?
A
- Nitroglycerine
- Sodium Nitroprusside
13
Q
Route of administration for Carboprost (Hemabate)
A
IM only
14
Q
Carboprost (Hemabate) is CI in which population? Why?
A
Asthmatics
* bronchospasm
* Mismatched V/Q ratio
* Hypoxemia
15
Q
What is Misoprostol used for?
A
Cervical ripening & Induction of labor
16
Q
Route that Misoprostol is given?
A
Intravaginally or Intrarectally
17
Q
Side effects of Misoprostol?
A
- Fever
- Chills
- N/V/D
18
Q
What is considered a “retained” placenta?
A
Failure to deliver placenta c̄ 30 minutes after fetus delivery
19
Q
Leading cause for primary/secondary PPH?
A
Uterine Atony
20
Q
Risk factors for retained placenta?
5
A
- Hx of retained placenta
- Preterm delivery
- Oxytocin use
- Preeclampsia
- Nulliparity
21
Q
Tx for retained placenta?
A
Manual removal or D&C
22
Q
Meds given for removal of Placenta? Why?
A
Small propofol/fentanyl
Or
Nitroglycerin 50-100 mcg
* Uterine dilation
23
Q
Difference between Placenta Previa and Abruption
A
Previa = Painless bleeding
Abruption = Painful bleeding
24
Q
What is a concealed abruption?
A
Absence of, or painless, bleeding
25
Signs of placental abruption?
| 3
* Vaginal, **painful** bleeding
* Uterine tenderness
* Uterine hyperactivity
26
Complications from placental abruption?
| 3
* Hemorrhagic shock
* Coagulopathy
* Fetal compromise/demise
27
How and what drugs would you use for Induction in Placenta previa/abruption?
**RSI**
* Low dose Prop
* Ketamine 0.5-1mg/kg
* Etomidate 0.3mg/kg
28
Tx of Uterine inversion?
* Put it back in (duh?)
* Nitroglycerin 200-250mcg
* Surgery if unsuccessful
29
Risk factors for Uterine inversion?
| 5
* Uterine atony
* Short umbilical cord
* Uterine anomalies
* Aggressive 3rd stage of labor management (tugging?)
* Innappropriate fundal pressure
30
Risk factors for Placenta previa?
| 6
* Prior uterine scar
* Prior Previa
* Advanced maternal age
* Smoking
* Male fetus
* Multiparity
31
Hallmark sign of Placenta previa & risk for?
* **Painless** vaginal bleeding
* increase risk of PPH
32
How will a Total previa be delivered?
Via C-section
33
What is the problem with Vasa previa?
Fetal vessels are **not protected** by placenta/umbilical cord
34
Risk with Vasa previa?
Rupture of membranes increase Tearing of fetal vessels
* High **Fetal mortality**
35
Risk factors for Vasa Previa?
| 5
* Placenta Previa
* Low-lying placenta in 2nd trimester
* Placental accessory lobes
* In vitro fertilization
* Multiple gestation
36
Where does placenta accreta implant?
**A**bnormally on the Myometrium of the Uterus
37
Where does the placenta USUALLY implant?
Endometrium
38
Where does placenta increta implant?
Into the myometrium
39
Where does placenta Percreta implant?
Past the myometrium
40
What risk comes from placenta Accreta/increta/percreta?
Intra-op massive hemorrhage
41
What are some treatment options for placenta accreta/increta/percreta
* Uterine artery embolization
* Hysterectomy
42
When is the onset of chronic HTN, gestational HTN & preeclampsia?
* Chronic: < 20 weeks gestation
* Gestational: 3rd Trimester
* Preeclampsia: >/= to 20 weeks
43
What features are present in pre-eclampsia, but not chronic/gestational HTN?
| 5
* Proteinuria
* Serum Uric acid > 5.5mg/dL
* Hemoconcentration (severe)
* Thrombocytopenia (severe)
* Hepatic dysfunction (severe)
44
Definition of preeclampsia?
* SBP > 140mmHg
* DBP > 90 mmHg
* Proteinuria
After 20 weeks gestation
45
What are some other symptoms of preeclampsia
| 5
* Epigastric/RUQ pain
* Cerebral symptoms
* Decrease Fetal growth
* Thrombocytopenia
* Increase Liver Enzymes
46
Pathophysiology of Preeclampsia
Deranged placental angiogenesis Increase constricted myometrial arteries w/ exaggerated vasomotor responsiveness increase **Decreased placental perfusion**
47
Demographic Risk factors for preeclampsia?
| 6
* Advanced maternal age >35 years
* Black/Hispanic ethnicity
* Hx of preeclampsia
* Family Hx of Preeclampsia
* Hx of placental abruption/ decrease fetal growth/fetal death
* Father w/ prior preeclamptic delivery
48
Medical risk factors for preeclampsia?
| 6
* Obesity
* Chronic HTN
* DM
* Chronic Renal disease
* SLE
* Antiphospholipid antibody syndrome
49
Obstetric risk factors for Preeclampsia?
* Multiple gestation
* Hydatidiform (Hy-dat-id-iform) mole
50
Primary cause of HTN related maternal mortality?
Cerebral hemorrhage
51
Other causes of HTN related maternal mortality?
| 5
* Pulm. edema
* Renal fail
* Hepatic Rupture
* Cerebral edema
* DIC
52
CNS effects from Preeclampsia?
| 5
* HA
* Hyperexcitability
* Hyperreflexia
* Coma
* Visual disturbances
53
CV effects of Preeclampsia
* increase vascular tone
* HTN
* End organ ischemia
54
Renal effects of Preeclampsia
* Decrease GFR
* increase Uric acid
* increase proteinuria
* Oliguria
55
Benefits of Magnesium Sulfate in tx preeclampsia?
| 5
* **Prevents seizures** by raising threshold
* Venous dilation
* CNS depression
* Decrease Uterine activity
* Decrease Hepatic fibrin deposits
56
How long is Mag. sulfate given?
Continued for 24 hrs post-partum
57
Normal serum magnesium levels?
1.8 - 2.2.... ish
58
Therapeutic range for Serum Magnesium?
5-9 mg/dL
59
How is magnesium eliminated
Almost entirely by **renal** excretion
60
What effects might a pt experience with a Serum Magnesium of 1mg/dL
Seizures
61
What effects might a pt experience with a Serum Magnesium of 12 mg/dL
Loss of deep tendon reflexes
62
What effects might a pt experience with a Serum Magnesium of 15-20 mg/dL
Respiratory arrest
63
What effects might a pt experience with a Serum Magnesium of >25 mg/dL
Asystole
64
Tx for Magnesium toxicity?
1 gm Calcium gluconate over 10 min
65
Major cause of hemorrhagic stroke in severe preeclampsia?
Uncontrolled HTN s/p laryngoscopy
66
1st line agent in Tx HTN in preeclampsia and when would you give it?
Labetalol with a SBP >160mmHg
67
MgSO4 effects on Rocuronium?
* Decrease onset time
* Increase recovery time by 25%
68
What does HELLP stand for?
*Hemolysis
* Elevated Liver enzymes
* Low Platelets
69
Clinical signs of Preeclampsia with HELLP syndrome?
| 6
* Epigastric pain
* Upper abdominal tenderness
* Proteinuria
* HTN
* Jaundice
* N/V
70
Diagnostic lab values for HELLP
* Bilirubin: > 1.2 mg/dL
* LDH: > 600 IU/L
* AST: > 70 IU/L
* Platelets: < 100k/mm3
71
Time frame for Late eclampsia?
48 hrs after delivery increase 4 weeks postpartum
72
3 most common sights of entry for an amniotic embolism?
* Endocervical veins
* Placenta
* Uterine trauma site
73
S/S of Amniotic fluid embolism?
| 6 + 1
**Abrupt:**
* Dyspnea
* Arterial Hypoxemia
* Cyanosis
* Seizure
* LOC
* HoTN
74
Tx for Amniotic fluid embolism?
A-OK (1mg atropine, 8mg ondansetron, 30mg ketolorac
* C-section
* ETT
* 100% O2
* Inotrope
* DIC tx
75
What statistics regarding Amniotic fluid embolism should you know?
* 80% mortality
* 80% experience cardiac arrest
76
Prevention measures for pre-term labor?
* 2nd trimester Cervical cerclage placed
* Progesterone 250 mg IM weekly 16-36 weeks
* Acute tocolytics (MgSO4, terbutaline)
77
When is a Cervical Cerclage placed?
12-26 weeks gestation
78
What is a cervical cerclage?
Surgery to prevent 2nd trimester fetal loss due to cervical incompetence
79
Most feared complication for Trial of Labor after C/S or Vaginal birth after C/S?
Uterine rupture (EMERGENCY)
80
Risk factors for prolapsed Umbilical cord?
* Preterm
* Breech
* Polyhydramnios
81
Tx for Umbilical cord prolapse?
**Emergency C-section**
82
What is shoulder dystocia?
Head is delivered but shoulders stuck on the pesky pubic bone
83
What needs to occur if the fetus shoulder is stuck on the pubic bone?
Deliver in 5 min or Emergency C-section
84
Nonobstetric procedures are ideal in which trimester? What should be avoided in the others?
* 2nd Trimester
* Surgery/GA in 1st/3rd trimester
85
Who should NOT be responsible for neonatal resuscitation?
The anesthesia provider attending the mother
86
What abnormal coagulation studies might be present in a pt with AFE?
* Thrombocytopenia
* Hypofibrinogenemia
* increase PT/aPTT
87
Classic Triad of AFE?
* Acute Respiratory distress
* Coagulopathy
* CV collapse
88
What medications do you administer to treat DIC caused by AFE?
**A-OK**
* Atropine - 1 mg
* Ondansetron - 8 mg
* Ketorolac - 30 mg
89
When are APGAR scores taken?
1 & 5 minutes
90
What does an APGAR score of 0-3 mean?
Indicates immediate resuscitation required
