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181 Cards in this Set
- Front
- Back
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what are the 3 leading causes of maternal mortality in the US
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*thromboemoblism (#1)
*hemmorhage (#2) *HTN dz (#3) |
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what are the HTN disorders of pregnancy
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*chronic HTN
*gestational HTN *preeclampsia |
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when does chronic HTN occur in pregnancy
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PRIOR to 20 wks gestation
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when does gestational HTN occur in pregnancy
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AFTER 20 wks gestation
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is there proteinuria with gesational HTN
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NO
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when does preeclampsia occur in preganancy
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AFTER 20 wks gestation
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is there proteinuria in preeclampsia
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YES
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CHRONIC htn complicates what amt of pregancies
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~5%
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what are the HEMATOLOGIC changes that occur with preeclampsia
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*hypercoagulability
*decreased fibrinolytic activity *plt activation -thrombocytopenia -increased plt aggregation -decreased sensitivity to prostacyclin |
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what kind of RENAL changes occur with preeclampsia
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*glomeular enlargement
*GFR decreased *protenuria *decreased urate clearance *oliguria |
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with preeclampsia glomerular enlargement leads to what
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ISCHEMIA
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with preeclampsia decreased urate clearance leads to what
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increased serum lactic acid
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what is refractory oliguria with preeclampsia
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30 ml/hr for 3 consecutive hrs unresponsive to a 300-500 ml bolus
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what type of RESP changes occur with preeclampsia
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*pharygolaryngeal edema
*pulmonary edema |
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what type of HEPATIC changes can occur in preeclampsia
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*epigastric or RUQ pain
*HELLP |
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what is HELLP
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*hemolysis
*elevated liver enzymes *low plts *other concerns (DIC, pulm edema, renal failure) |
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what is HELLP often tx with
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DEXAMETHASONE
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what is placental abruption
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partial or complete seperation of the placenta before delivery of the fetus
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what are the risk factors for placental abruption
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*HTN
*preeclampsia *cocaine use *ETOH use *smoking *prev hx of abruption |
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what is the management of placental abruption
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*delivery
*restoration of blood volume *management of accompanying DIC |
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placental abruption may present how
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may present as vaginal bleeding or blood loss may be hidden
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what are some NEUROLOGIC changes that can occur with preeclampsia
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*severe HA
*visual disturbance *hyperreflexia *CNS excitability |
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what is the definition of eclampsia
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convulsions and/or coma caused by coincidental neuro dz which occurs during preg or the puerperium in a woman whose condition also meets the criteria for preeclampsia
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what are the proposed causes for eclampsia
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*cerebral vasospasm
*ischemia *edema *hemorrhage *HTN encephalopathy *DIC |
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what is the management of eclampsia
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*establish a patent airway
*o2 *stop/prevent further sz activity *antihypertensives if indicated *expedite delivery |
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how would you stop/prevent further sz with eclampsia
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*bzd
*mag |
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what is the loading dose of mag in eclampsia
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4-6 g IV over 20 min
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what is the infusion dose of mag for eclampsia
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1-2 g/hr
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what are the s/e of MAG when used as an anti-convulsant for preeclampsia
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*N/V
*pain *muscle weakness *hyporeflexia |
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what is the treatment for MAG toxicity when mag is used for preeclampsia
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*calcium
*Na bicarb if acidotic *vent support as needed |
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hypermagnesemia has what effect on NON-depolarizing NMB
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enhances sensitivity to all of them
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what kind of change is there in thromboelastography in pts receiving mag sulfate
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NO change
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what kind of change is there in peri-op bleeding with pts receiving mag sulfate
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NO change
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what are the anti-HTN used in preeclampsia
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*hydralazine
*latetalol *NTG *nipride *nifedipine *esmolol |
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what is the most commonly used antihypertensive used in preeclampsia
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HYDRALAZINE
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how does hyralazine work in preeclampsia
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preferentially relaxes arterioles decreasing SVR
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what is the usual dose of HYDRALAZINE in preeclampsia
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5 mg every 20 mins up to 20 mg total
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there is min effect on what blood flow with hydralazine in the usual dosage range when used for preeclampsia
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*uteroplacental
*renal *umbilical |
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labetolol is what kind of drug
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combined alpha and beta adrenergic blocker
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what is the ratio of alpha to beta blokade with labetolol when given IV
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1:5-10
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how does labetalol work when given as an antihypertensive in preeclampsia
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decreases SVR WITHOUT increasing HR
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with labetalol as an antihypertensive for preeclampsia uterine blood flow is well preserved at what doses
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doses </= 1 mg/kg
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NTG is what kind of drug
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vascular smooth muscle relaxant
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NTG has the greatest effect on venous or arterial circulation
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VENOUS
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with NTG there is a greater reduction in preload or afterload
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PRELOAD
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which antihypertensive drug is used by some to attentuate the hypertensive response to intubation
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NTG
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nipride is what kind of drug
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vascular smooth muscle relaxant
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nipride has a greater effect on arterial or venous side
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ARTERIAL
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with nipride there is a greater reduction in preload or afterload
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AFTERLOAD
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there is a concern about what with nipride when it crosses over the placenta when it is used as an antihypertensive for preeclampsia
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cyandie toxicity
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what is the advantage of using nipride as an antihypertensive for preeclampsia
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*effect is brief
*easy to titrate |
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nifedipine is what kind of drug
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calcium channel blocker
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nifedipine has what kind of vasodilation
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predominately arterial and arteriolar
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what is the typical inital dose of nifedipine when used as an antihypertensive for preeclampsia
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10 mg po
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when using nifedipine for an antihypertensive for preeclampsia you may see exaggerated hypotension when
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when used with mag sulfate
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which antihypertensive used for preeclampsia is cardioselective
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ESMOLOL
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which antihypertensive used for preeclampsia is ultrashort acting
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ESMOLOL
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which antihypertensive used for preeclampsia is useful prior to intubation to attentuate the hemodynamic response
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ESMOLOL
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what is the typical dose of esmolol used for preeclampsia
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1 mg/kg
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why is epidural analgesia the preferred tech for labor analgesia in the preeclamptic pt
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*provides superior analgesia
*attenuates HTN response to pain *decreases circulating catecholamines *may improve intervillous blood flow *preeclamptic pt are at increased risk for C/S |
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sickle cell dz in pregnancy increases the incidence for what
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*preterm labor
*placental abruption *placenta previa *gestatational HTN |
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what is the anesthetic management of sickle cell dz in pregnancy
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*adequate pain control preferably with epidural
*maintain intravascular volume *supplemental o2 *maintain normothermia *avoid peripheral venous stasis *RBC if needed for o2 carrying capacity |
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autoimmunue thrombocytopenic purpura is formerly known as what
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ITP
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autoimmune thrombocytopenic purpura is managed by OBs how
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with corticosteriods and occassionally IV immunoglobin
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von willebrand dz is what kind of trait
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autosomal DOMINANT
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treatment of von willebrands dz in pregnancy typically consists of what
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DDAVP at onset of labor and q 12 hrs
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other than the "usual" treatment for von willebrands in pregnancy what other tx may it require
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*FFP
*cryo *humate-P |
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are ASA and NSAIDs considered a contraindication to regional anesthesia
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generally NOT
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according to ASRA recommendations needle placement for an epidural/spinal should be when after the last dose of LMWH
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10-12 hrs
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according to ASRA recommendations in pts receiving high dose LMWH needle placement for epidural/spinal should be delayed until when after last dose
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24 hrs
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according to ASRA recommendations LMWH dosing can be resumed when after sx
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6-8 hrs
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according to ASRA recommedations if an epidural cathether is left in place is should be removed when after the last dose of LMWH
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at least 10-12 hrs
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according to ASRA recommendations LMWH dosing can be resumed how long after epidural catheter removal
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2 hrs
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hypercoaguable states are contributed to in pregnancy by a deficency of what
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*protein C
*protein S *antithromin III |
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protein C does what
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inhibits factors V and VIII
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protein S does what
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functions as a cofactor to protein C
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antithromin III does what
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inactivates thrombin and multi other factors
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how is protein C deficiency tx
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with anticoagulation
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how is antithrombin III deficiency tx
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*anticoagulation
*antithrombin III concentrate |
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symtoms of asthma often do what during pregnancy
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IMPROVE
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what type of analgesia provides excellent pain relief and reduces stimulus to hyperventilation
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EPIDURAL
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regarding asthma in pregnancy regional anesthesia with c-section avoids what
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potential for bronchospasm at intubation and emergence
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what is the leading cause of heart dz in pregnancy
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congenital heart dz
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what type of shunts are usually well tolerated during pregnancy
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*small L to r
-typically ASD or VSD |
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what is important with shunts in pregnancy
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*adequate pain control
*meticulous attention to air embolism |
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what kind of cardiac shunting in pregnancy carries a high mortality rate
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*R to l
-primary pulm HTN -eisenmengers |
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primary pulm HTN or eisenmengers with pregnancy pose a significant risk when
|
with single shot spinal anesthetic or rapidly dosed epidural with epi
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ischemic heart dz is rare in pregnancy but is increasing in frequency in what types of people
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*older mothers
*obesity/DM *oral contraceptives *cocaine abuse |
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what are the physiologic changes of pregnancy/labor which may lead to ischemia
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*increased HR
*increased myocardial wall tension *increased oxygen consumption *autotransfusion of 300-500 ml with contraction |
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peripartum cardiomyopathy has an onset of when
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in final month of pregnancy or first 5 months postpartum
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what is the etilogy of peripartum cardiomyopathy
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unknown could be
*viral *autoimmune *toxic |
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what amt of pts have complete recovery from peripartum cardiomyopathy
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50%
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how should CPR be perfomed during pregnancy
|
just like in the non-pregnant pt but with uterine displacement to min aortocaval compression
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arrythmias are less common are more common during pregnancy
|
MORE common
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what type of arrythmias usually occur during pregnancy
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*atrial
*rarely of HD significance |
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what drugs have been used safely during pregnancy to tx arrythmias
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*digoxin
*quinidine *beta-blockers *lidocaine *adenosine |
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with mutiple sclerosis there is an increased frequency of relapse when in pregnancy
|
POSTPARTUM
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with spinal cord injury and pregnancy what type of anesthesia is useful for the prevention of autonomic hyperreflexia
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epidural or spinal
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with spinal cord injury and pregnancy what type of anesthesia may be needed for severe resp insufficiency
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GETA
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with spinal cord injury and pregnancy you should AVOID the use of succinylchoine when
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during the period of denervation injury
|
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with myasthenia gravis and pregnancy you should assess the degree of what involvement
|
resp/bulbar
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with myasthenia gravis and pregnancy what type of anesthesia is useful in avoiding the resp depresssion of opioids
|
REGIONAL
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with myasthenia gravis what type of anesthesia is preferred for c-section unless there is sig resp or bulbar involement
|
REGIONAL
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what is another name for benign intracranial HTN
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pseudotumor cerebri
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what is benign intracranial HTN
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globally increased CSF pressure with the absence of focal intracranial lesions
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what amt of benign intracranial HTN cases worsen with pregnancy
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50%
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what are some isolated neuropoathies that are more common with pregnancy
|
*bells palsy
*carpal tunnel syndrome *meralgia parsthetica |
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bells palsy in the pregnant pt is sometimes tx how
|
with prednisone
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pregnancy results in progressive peripheral resistance to insulin likely involving an increase in what counter-regulatory hormones
|
*placental lactogen
*placental growth hormone *cortisol *progesterone |
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with cocaine euphoric effects are related to what
|
prolongation of dopaminergic activity in the limbic system and cortex
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with cocaine CV effects result from what
|
an accumulation of catecholamines
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pregnancy may do what to the CV effects from cocaine
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result in an increased sensitivity
|
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though regional anesthesia is likely safer than GETA in cocaine abuse and pregnancy what are the possible problems
|
*at risk for thrombocytopenia
*increased risk for hypotension *pt with depleted catecholamines may be relatively unresponsive to ephedrine *often complain of pain despite adequte level of anesthesia |
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with general anesthesia MAC may be what in CHRONIC cocaine use and pregnancy
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DECREASED
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with general anesthesia MAC may be what with ACUTE cocaine use and pregnancy
|
INCREASED
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what drugs do you want to AVOID with cocaine abuse and pregnancy
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*drugs that sensitize the myocardium (halothane)
*drugs that release catecholamines (ketamine) *drugs that cause tachycardia (atropine) |
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what drugs can be used in the management of cocaine induced HTN in pregnancy
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*hydralazine
*labetalol *NTG + labetalol |
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what drug used in the management of cocaine induced HTN causes profound tachycardia
|
HYDRALAZINE
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what drug used in the managment of cocaine induced HTN has no improvement in uterine blood flow
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HYDRALAZINE & LABETALOL
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which drug used in the management of cocaine induced HTN lowers HR to baseline
|
LABETALOL
|
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cocaine crosses the placenta how resulting in what
|
*freely crosses
*resuting in direct effects on the fetus as well as indirect effects from maternal exposure |
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what is the most accurate predictor of cocaine abuse in the pregnant pt
|
absence of prenatal care
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cocaine abusing parturients have a high frequency of concurrent abuse of what
|
OPIOIDS and other drugs
|
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amphetamines cause profound stimulation of what
|
CNS
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amphetamines do what in the body
|
cause catecholamine release from adrenergic nerve terminals and inhibition of reuptake
|
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what are the s/s of cocaine abuse
|
*HTN/tachycardia
*convulsions *hyperreflexia *tremors *hyperpyrexia *acidosis *emotional libility *dilated pupils |
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what are the symtoms of amphetamine abuse
|
*HTN/tachycardia
*arrhtymias *agitation *confusion *dilated pupils *hyperreflexia |
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withdrawal symptoms from opioids occur within how long from last dose
|
~ 12 hrs
|
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what are the withdrawl s/s from opioids
|
*yawning
*tearing *fever *sweating *rhinorrhea *diarrhea *dehydration |
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regarding marijuana and pregnancy the most common effect is what
|
TACHYCARDIA
|
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tachycardia seen with marijuana and pregnancy can be effectively treated how
|
with beta blockers
|
|
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with pregnancy CHRONIC marijuana use may result in what
|
*resp infection
*myocardial depression |
|
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ETOH is consumed by what amt of pregnant women in the US
|
~15%
|
|
|
consumption of ETOH while pregnant can lead to what
|
*ETOH related neurodeveolpment disorder
*fetal alcohol syndrome |
|
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what type of anesthesia is preferable in the presence of ETOH with pregnancy if there is no coagulopathy or severe neuropathy
|
REGIONAL
|
|
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what are the physical charac of a fetal alcohol syndrome baby
|
*skin folds at corner of eye
*low nasal bridge *short nose *indistinct philtrium *small head circumference *small eye opening *small midface *thin upper lip |
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what are conditions warrenting immediate delivery with preeclampsia
|
*severe persistant HTN
*progressive throbocytopenia *liver dysfuction *progressive renal dysfunction *premonitory s/s of eclampsia *evidence of fetal jeopardy |
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mild vs severe preeclampsia is based on what parameters
|
*BP
*urine protein *UO |
|
|
where is the problem with preeclampsia
|
the PLACENTA
|
|
|
what are the causes of preeclampsia
|
multifactorial
*immunologic *genetic *endothelial factors *plt factors *ca/angiotension II *coagulation factors *hepatic fatty acid metabolism |
|
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what is colloid osmotic pressure like with preeclampsia
|
much lower than with a normal pregnant pt
|
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the combination of increased vascular permeability with decreased colloid oncotic pressure in preeclampsia results in what
|
increased loss of intravascular fluid into the interstitial space and can result in pulm edema or airway swelling
|
|
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regarding CV changes with preeclampsia group 1 is what
|
*increased CO
*normal or increased SVR *normal or decreased blood volume |
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regarding CV changes with preeclampsia group 2 is what
|
*normal CO
*increased SVR *decreased blood volume |
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regarding CV changes with preeclampsia group 3 is what
|
*depressed LV fxn
*markedly increased SVR *markedly decreased blood volume |
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regarding uteroplacental vasculature with preeclampsia vasodilators include what
|
*PGI2
*NO |
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regarding uteroplacental vasculature with preeclampsia vascoconstrictors include what
|
*angiotension II
*TXA2 *serotonin *endothelin |
|
|
what is the drug of choice for anticonvulsant in preeclampsia
|
MAG SULFATE
|
|
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what drug has been shown in preeclampsia to be superior to phenytoin and dzp in preventing recurrent sz
|
MAG SULFATE
|
|
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does mag sulfate when used as an anticonvulsant in preeclampsia alter the progression of the dz
|
NO--only used to prevent sz
|
|
|
what sensory level is needed with an epidural for a c-section
|
T4-T6
|
|
|
what is the number one cause of myocardial ischemia in pregnant women
|
COCAINE ABUSE
|
|
|
should succinlycholine be AVOIDED with guillian-barre syndrome with pregnancy
|
YES
|
|
|
should succinylcholine be AVOIDED with post-polio with pregnancy
|
NO-its ok to use
|
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with opioids and pregnancy IUGR and fetal risk are primarily related to what
|
*direct opioid use
*concurrent use of other drugs *poor maternal nutrition *infection *opioid withdrawal |
|
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with an infant delivered to a mother chronically abusing opioids how should the infant be treated
|
*the neonate may require resp support
*do NOT tx the infant with narcan |
|
|
does asymptomatic HIV infection contraindicate regional anesthesia
|
NO
|
|
|
what increases the risk of spinal/epidural abscess and disc space infections
|
chronic abuse of opioids
|
|
|
alcohol abusing pts are less or more sensitive to the depressant effects of anesthesia
|
MORE
|
|
|
what are the components of the apgar scoring system
|
*HR
*muscle tone *color *resp effort *reflex irritablity |
|
|
what is the intervillious space
|
where maternal and fetal blood mix
|
|
|
with contractions once pt is comfortable (once pain is under control) what is the HR response
|
reflex bradycardia
|
|
|
why do women have dilutional anemia in pregnancy
|
there is a greater increase in plasma volume than in RBC
|
|
|
in pregnancy there is a direct correlation b/t thrombosis and what
|
maternal Hgb concentration
|
|
|
regarding FRC:CC ratio if
CC > FRC what occurs |
low V/Q (small airway closure)
|
|
|
regarding FRC:CC ratio if
CC >> FRC what occurs |
ATELECTASIS
|
|
|
regarding FRC:CC ratio if
FRC > CC what occurs |
that is NORMAL
|
|
|
pregnant pts should be considered full stomachs after when
|
end of 1st trimester
|
|
|
what is the end result of renal changes with pregnancy
|
DECREASED bun and creatinine
|
|
|
with pregnancy the induction dose of thiopental is changed how
|
reduced by ~ 35%
|
|
|
with pregnancy the elimination half life of thiopental is changed how
|
INCREASED from 11.5 to 26.1 hrs d/t increased volume of distrubution
|
|
|
what amt of uterine blood flow goes thru the intervillous space
|
80%
|
|
|
what factors contribute to increased uteroplacental blood flow
|
*growth of new blood vessels (early in preg)
*vasodilation |
|
|
ephedrine has what kind of effect on UTERINE art
|
doesn't have a constrictive effect
|
|
|
what are drugs that rapidly cross the placenta
|
*inhalational agents
*N2O *IV induction agents *dzp>mdz *opioids *LA *atropine *antihypertensives *ephedrine *cocaine *warfarin |
|
|
what are drugs that have little to no transfer across the placenta
|
*MR
*anticholinesterases *glycopyrrolate *LMWH |
|
|
what is the definitive treatment for preeclampsia
|
delivery of the PLACENTA
(not delivery of the baby) |
|
|
with a pregnant pt if hypotension occurs with no blood externally what should be a differential dx
|
PLACENTAL ABRUPTION
|
|
|
what is the first line drug used in OB as an antihypertensive for preeclampsia
|
HYDRALAZINE
|
|
|
most hematomas occur when with LMWH
|
with removal
|
|
|
with asthma and pregancy if a general anesthetic is used what induction agents are appropriate
|
*thiopental
*ketamine *propofol |
