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26 Cards in this Set
- Front
- Back
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Drug categories and pregnancy
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Category A = A Ok. Generally considered safe
-taken by a large number of pregnant women and women of childbearing age without any proven increase in freq of malformations or direct or indirect harm to fetus Category B - Buggered if I know. limited data available Drugs which have been taken by a limited number or pregnant women and women of childbearing age without an increase in malformations or direct or indirect harmful effects to the fetus (B does not imply improved safety cf C) Category C - Careful. May be Harmful Drugs which owing to pharmacological effects have caused or are suspected of causing harmful effects on the human fetus without causing malformations. Effects may be reversible Category D - Danger - risk of irreversible harm Drugs which have caused or suspected or expected to have caused an increased incidence of human fetal malformations or irreversible damage. Also have adverse pharmacodynamic effects Category X - X men. High risk teratogenesis Drugs which have such a high risk of causing permanent damage to the foetus that shouldnt be used during pregnancy or where there is the possibility of pregnancy |
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Surgery in pregnancy
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Pre-op
-CTG monitoring from 18/40, variability from 25/40. GA will decrease variability -decision between laparoscopy vs laparotomy. Increased fetal acidosis with laparoscopy but no difference fetal outcomes. Intra-op - prophylactic use of tocolytics not recommended. If goes into labour then can use |
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Gestational DM
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consider
- larger baby increased risk of CS - larger baby, increased risk of PPH - 1st on list to minimise fasting - post op insulin rarely required |
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Placental abruption
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- early seperation of placenta from uterus
- 25% of APH - bleedimg can be concealed - beware coagulopathy (DIC) |
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Multiple sclerosis
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- increased risk of relapse in 1st 3/12 post delivery
- risk of relapse decreases throughout pregnancy - epidural doesnt increase risk of relapse - spinal may - use lowest concentration of LA able |
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ALS in pregnancy
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same as ALS generally, additions
- left lateral tilt - add cricoid pressure - CPR higher on chest - early intubation - hysterotomy if CPR longer than 5 mins |
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PDPH
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- risk is ~50-80% is sustain dural puncture
- headache thought to be due to CSF leak being greater that CSF production, with stretching of meninges - clinical features bi-frontal headache neck stiffness onset 24-28/24 postural - worse on standing better supine associated with photophobia, diplopia, tinnitus, abducens nerve palsy rarely causes SDH |
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Treatment for PDPH
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- symptomatic relief with position but no effect on incidence of PDPH
- weak evidence for leaving intrathecal catheter insitu for 24/24 - adequate fluid intake - caffeine has weak evidence - sumatriptan acts to decrease intracerebral vasodilation but causes coronary vasoconstriction - epidural blood patch |
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Epidural blood patch
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- success is 60-90% on 1st attempt
- MOA: via accelerated fibrosis of dural tear and also by increasing epidural pressure to limit leak of CSF - gain consent - perform at same or lower space as blood will spread cephalad - 2 anaesthetist technique - strict asepsis - inject 20-30mls of blood or until develops pressure - bed rest for 2/24 then slow mobilisation |
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AFE (background)
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-rare
- high mortality and morbidity (85% survivors have neurological impairment) - presents as sudden maternal collapse associated with hypotension, hypoxaemia and DIC - occurs when foetal cells, amniotic fluid enters the maternal circulation - most cases occur during labour, but can also occur during procedures in 2nd trimester, deivery and closed abdominal injury |
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AFE (pathophysiology)
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- AFE enters maternal circulation down pressure gradient
- thought syndrome is immune response rather than embolic - stimulate inflammatory cascade leading to similar picture as anaphylaxis - stage 1: AFE enters pulmonary circulation leading to release of inflammatory mediators, pulmonary constriction, pulmonary hypertension, R heart failure, hypoxaemia and hypotension stage 2: LVF and pulmonary oedema. DIC |
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AFE (presentation)
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CVS: increase in both systemic and pulmonary vascular resistance, LVF, myocardial depression
Resp: hypoxaemia, ARDs often results Coagulation: DIC |
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AFE (diagnosis)
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no pathognomic marker
diagnosis of exclusion presence of foetal cells in PA is supportive\ serum tryptase sialyl Tn |
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Pre-eclampsia
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-multisystem disorder characterised by oedema, HTN and proteinuria
-occurs after 20/40 |
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Pre-eclampsia (classification)
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-mild
BP >140/90 proteinuria >300mg/day (or 2 specimens >4/24 apart with >2+ on dipstick -severe BP >160/110 proteinuria >5g/day or oligura <400mls/day CNS symptoms RUQ pain Pulmonary oedema IUGR |
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Pre-eclampsia risk factors
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- primigravida
- previous PET - obesity -DM - multiple pregnancy - advanced maternal age -preexisting HTN |
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Pre-eclampsia treatment goals
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- treat BP eg hydralazine 5-10mg bolus then 5mg or labatelol eg 20mg bolus x2 then 20mg/hr and titrate up
- prevent seizures eg Mg 4g then 1-2g/hr with aim serum Mg 2-4mmo/L. Continue until diuresis established. Seizures 40% antepartum, 20% intrapartum and 40% post partum - fluid restrict (aim CVP 3-5mmHg) - deliver placenta (regional desirable as exaggerated response to laryngoscopy) - 3rd stage management eg avoid ergometrine |
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Pre-eclampsia complications
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maternal
-placental abruption - eclampsia - ICH - liver rupture -APO - renal failure - DIC Foetal - IUGR -FDIU Neonatal -hypoxia |
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Placenta praevia
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risk factors
- multiple C sections - increased parity - increased maternal age - mutliple gestation |
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reason for increased risk of bleeding with placenta praevia
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- obstetricians cut into anterior placenta during uterine incision
-following delivery low placenta uterine implantation doesnt contract as well as fundal position - increased risk of placenta accreta |
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Placental abruption
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-defined as premature placental seperation
- risk factors: overdistended uterus eg twins, polyhydramnios, pre-eclampsia, Phx abruption - presentation: bleeding with pain and abdominal distension (beware retroplacental abruption as can be concealed) -risk: underappreciated blood loss, DIC and increased risk of PPH Mx: resuscitate, GA prob safer than regional |
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Cord prolapse
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-obstetric emergency as compression of cord by presenting part is universal
- initial management: keep mother in lateral position with head down to keep pressure off cord - operative: fastest and safest way of inducing anaesthesia. Prob GA as hard to position for regional unless epidural insitu as time critical |
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risk factors for epidural abscess
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- immunocompromised eg DM, ETOH abuse, steroids
- disrupted spinal column - source of infection eg UTI, IVDU |
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MAGPIE trial
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-prospective RCT comparing Mg to placebo
- large - intention to treat analysis - published Lancet 2002 Results - decrease in eclampsia (NNT 1:90 all comers, 1:60 in severe pre-eclampsia) - trend towards decreased placental abruption - trend towards decrease in mortality |
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Causes of maternal death
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Indirect:
- cardiac - psych - sepsis Direct: - AFE - PE - Eclamptic related - sepsis - haemorrhage |
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uterotonics
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- syntocinon up to 10units IV
hypotension nausea and vomiting - ergot 250mcg IV/IM hypertension nausea and vomiting -PGF2a bronchospasm hypertension - PGE1 - misoprostol |
