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139 Cards in this Set
- Front
- Back
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How does MgSO4 work on preeclamptic pts
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Elevates seizure threshold, a positive side effect is that it also decreases blood pressure and increases uterine blood flow
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What is the dose for MgSO4?
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4gm loading dose followed by
1-2gm/hr infusion |
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What is the therapeutic level for MgSO4?
a) 1-3mg/L b) 3-5 mg/L c) 6-8mg/L d) 10-12mg/L |
6-8mg/L
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If MgSO4 serum level is 12-14mg/L what type of symptoms would you expect to see?
a) ventilatory insufficiency b) cardiac asystole c) progressive respiratory depression d) positive patellar reflexes e) absent patellar reflexes |
progressive respiratory depression
absent patellar reflexes |
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If MgSO4 serum level is 22-24mg/L what type of symptoms would you expect to see?
a) ventilatory insufficiency b) cardiac asystole c) progressive respiratory depression d) positive patellar reflexes e) absent patellar reflexes |
ventilatory insufficiency
cardiac asystole absent patellar reflexes |
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At what MgSO4 serum level do patellar reflexes disappear?
a) 6-8mg/L b) 1-2mg/L c) 9-10mg/L d) immediately after giving loading dose |
9-10mg/L
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Maternal O2-Hb curve
a) shifted to the left b) shifted to the right c) high affinity for O2 d) low affinity for O2 |
shifted to the right
low affinity for O2 (this allow O2 to be shunted to the baby) |
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Fetal O2-Hb curve
a) shifted to the left b) shifted to the right c) high affinity for O2 d) low affinity for O2 |
shifted to the left
high affinity for O2 |
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Right shift on O2-Hb curve
a) high O2 binding b) low O2 binding c) low pH d) low temp e) high temp f) high 2-3 DPG g) low 2-3 DPG |
low O2 binding
low pH high temp high 2-3 DPG |
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Left shift on O2-Hb curve
a) high O2 binding b) low O2 binding c) high pH d) low temp e) high temp f) high 2-3 DPG g) low 2-3 DPG |
high O2 binding
high pH low temp low 2-3 DPG |
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What dose of Thiopental will decrease uterine blood flow?
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a dose > 4mg/kg
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What dose of Ketamine will decrease uterine blood flow?
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a dose >2mg/kg
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Inhalation agents with what MAC will cause decrease uterine blood flow
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any MAC GREATER than 0.5 will decrease uterine blood flow
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What do MgSO4, Ntg, Hydralazine do to uterine blood flow increase/decrease it
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increase it
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When does cardiac output peak in pregnant woman
a) early 1st stage of labor b) late 1st stage c) second stage d) post-partum period |
Post partum period increases by 80%
in the first 48hrs |
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When does cardiac output return to normal in a post partum woman?
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2 weeks after delivery
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When is a pregnant woman considered to have a full stomach?
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at 15 weeks and beyond
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Pregnant women have a lower pseudocholinesterase level, when is it decreased the most?
a) during labor b) 1 day post partum c) 3 days post partum |
3 days post partum, it is decreased by 60%!
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Some causes of uterine rupture include
a) previous C-section b) polyhydraminos c) multiple pregnancies d) large baby |
previous C-section
polyhydraminos multiple pregnancies large baby |
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When placing an epidural needle is the bevel up or down?
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The needle is parallel and bevel up
DECREASES RISK OF PDPH |
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When you add bicarb to a local anesthetic what does it do?
a) increase intensity b) increase duration c) increase onset |
increase onset it does this by changing the PKA of the LA bringing it closer to physiologic pH
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When epinephrine is added to a local anesthetic what does it do?
a) increase intensity b) increase duration c) increase onset |
increase intensity
increase duration this related to lipid solubility |
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When is a pregnant woman most likely to have fluid overload?
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post-delivery because of redistribution
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Why would you not want to use Epi in a test dose on a patient with Eisengmeyer syndrome?
a) due to the tachycardia that can happen with the epi b) due to the increase in pulmonary vascular resistance that can be caused |
due to the increase in pulmonary vascular resistance that can be caused
Pt's with this disease already have Pulm HTN and this could exacerbate it. DON'T USE EPI ON ANY PT WITH A SHUNT! |
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Why would you not want to use Epi in a test dose in a patient with a cardiac stenotic lesion?
a) due to the tachycardia that can happen with the epi b) due to the increase in pulmonary vascular resistance that can be caused |
due to the tachycardia that can happen with the epi
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You need to relax a uterus for what reasons
a) breech/twins b) uterine tetanus c) post partum hemorrhage d) inverted uterus |
breech/twins
uterine tetanus post partum hemorrhage (because may need to manipulate uterus if retained placenta or inverted uterus) inverted uterus |
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What MAC would be used in the case of uterine atony?
a) 0.5 b) > 1 MAC |
> 1 MAC
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What drug is used for uterine atony? What is the dose?
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NTG 50-100mcg
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With general anesthesia besides airway, what is the second most common risk/adverse outcome in a pregnant woman?
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Aspiration
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Signs & symptoms of aspiration include
a) decreased PaO2 b) increased pressures c) wheezing d) cyanosis e) increased HR f) Increased BP |
decreased PaO2
increased pressures wheezing cyanosis increased HR Increased BP (initially, then will decrease) |
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What is the treatment for aspiration? (choose all that apply)
a) Suction b) Positive Pressure c) antibiotics d) steroids e) albuterol |
Suction
Positive Pressure albuterol NO steroids or antibiotics, study show they may actually cause more harm than good |
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During anesthesia, when does the pregnant woman have the highest risk of aspiration?
a) on intubation b) after delivery c) at extubation |
after delivery
at extubation |
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Which of the following meds can cause increased bleeding in a pregnant woman
a) Ca Channel blockers b) NTG c) Nipride d) B-blockers |
Ca Channel blockers (blocks uterine contraction d/t decreased Calcium)
NTG (vasodilation) Nipride (vasodilation) |
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What is the differential diagnosis for a post dural puncture headache?
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POSITION! If patient lays down & headache goes away IT IS A PDPH!
when sitting up the decrease in CSF causes sagging of ventricles which causes the headache |
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What are the signs & symptoms of a PDPH
a) fever b) headache c) neck pain d) nausea |
headache
neck pain |
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Most effective way to treat a PDPH?
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Epidural blood patch
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Uterine rupture
a) pre-term hemorrhage b) intra-partum hemorrhage c) post-partum hemorrhage |
can be found in all
pre-term hemorrhage intra-partum hemorrhage post-partum hemorrhage |
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Placenta abruption
a) painful bleeding b) non-painful bleeding c) pre-partum hemorrhage d) intra-partum rupture |
painful bleeding
pre-partum hemorrhage |
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Placenta previa
a) painful bleeding b) non-painful bleeding c) pre-partum hemorrhage d) intra-partum rupture |
non-painful bleeding
pre-partum hemorrhage |
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Post-partum hemmorhage
a) uterine atony b) placenta acreta c) retained placenta d) placenta previa |
uterine atony
placenta acreta retained placenta |
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Top 4 reasons for pregnancy related deaths according to WHO
a) Hemorrhage b) other direct causes c) HTN disorders d) Embolism e) abortion |
Hemorrhage
other direct causes HTN disorders Embolism |
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Top 4 reasons for pregnancy related deaths in NC 1995-1999
a) cardiomyopathy b) hemorrhage c) PIH d) CVA e) Amniotic fluid embolism |
#1 cardiomyopathy
#2 hemorrhage #3 PIH #4 CVA |
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T/F there is a huge disparity in the number of pregnancy related deaths related to race/socioeconomics
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True!
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While there has been a decrease in birth related problems r/t regional anesthesia, ASA closed claims courts have seen a huge shift in what?
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The number of claims while they are related to regional anesthesia are trivial reasons like, headache and discomfort
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The number one reason for women to die in the world
a) car accidents b) cardiomyopathy c) childbirth d) CVA |
childbirth
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Pregnant women with cardiomyopathy
a) C-section is always indicated b) vaginal birth is preferred c) should be on anticoagulants d) should be induced early e) do not have to be induced early |
vaginal birth is preferred (with passive second stage delivery)
should be on anticoagulants do not have to be induced early |
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What drugs should be avoided in pregnant women
a) ACEI's b) amiodorone c) verapamil d) propanolol e) anticoagulants |
ACEI's
amiodorone verapamil |
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When delivering a baby of a mother with cardiomyopathy what is important to remember about the 2nd stage of labor?
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it should be PASSIVE labor, where the mom is NOT allowed to push (Valsalva increases ventricular work) and the baby is delivered with forceps
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Your pregnant mother has aortic stenosis which is the best option for a regional anesthetic
a) Continuous spinal b) Epidural c) CSE |
Epidural because preload is not compromised like it is with a spinal technique
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Definition of peripartum cardiomyopathy includes
a) ejection fraction <45% b) development of cardiac failure in the last month or within 5 months c) absence of identifiable cause for the heart failure d) absence of recognizable heart disease before last month of pregnancy |
ejection fraction <45%
development of cardiac failure in the last month or within 5 months absence of identifiable cause for the heart failure absence of recognizable heart disease before last month of pregnancy |
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Why is retained placenta the most common cause of serious blood loss?
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Because of the uterine atony associated with it! Uterus will NOT contract if it is not COMPLETELY empty!
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Which pregnant patients would it be important to get coags on
a) abruptio b) IUFD c) Uterine rupture d) one who is on Heparin/LMWH |
abruptio
IUFD one who is on Heparin/LMWH |
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Why is the SVR decreased in 3rd trimester pregnant women?
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Because of the increase in progesterone, prostacylclin and development of placental unit
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The type of hemorrhage with the highest likelihood of DIC
a) Placenta accreta b) Placenta abruption c) Placenta previa |
Placenta abruption
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Risk factors for placenta accreta
a) known placenta previa b) 4 prior C-sections c) large neonate d) polyhydramnios |
known placenta previa
4 prior C-sections |
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With placenta abruption when would it be safe to deliver vaginally (the preferred method)?
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Reassuring FHT
No ongoing blood loss No hypovolemia No coagulopathy |
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Placenta Previa
a) must do a C-section b) vaginal delivery preferred c) delivery stops bleeding d) is associated with DIC |
must do a C-section
delivery stops bleeding |
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T/F long term pitocin down regulates pitocin receptors
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TRUE, May lead to uterine atony!
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Pregnant woman with asthma & HTN has uterine atony what is the appropriate medication for the atony
a) methergine (ergonovine) b) prostglandin F2 alpha c) pitocin |
pitocin
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Pregnant woman with HTN has uterine atony what is the appropriate medication for the atony
a) methergine (ergonovine) b) prostglandin F2 alpha c) pitocin |
Pitocin or maybe prostglandin F2 alpha if used with caution
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Pregnant woman with asthma has uterine atony what is the appropriate medication for the atony
a) methergine (ergonovine) b) prostglandin F2 alpha c) pitocin |
Pitocin or methergine
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Pregnancy induced HTN
a) >20wks gestation b) prior to 20 weeks gestation |
>20wks gestation PREECLAMPSIA
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Chronic HTN
a) >20wks gestation b) prior to 20 weeks gestation |
prior to 20 weeks gestation
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One theory for preeclampsia is
a) increased thromboxane relative to prostacycline b) decreased thromboxane relative to prostacycline |
increased thromboxane relative to prostacycline (vasoconstriction leading to dying tissue and the cascade which leads to decreased O2, decreased uteroplacental perfusion
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Preeclampsia
a) proteinurea b) edema c) HTN d) seizures |
proteinurea
edema HTN SBP>140 DBP>90 |
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Severe Preeclampsia
a) SBP>140, DBP>90 b) SBP>160, DBP>110 c) protein > 5 d) oliguria e) HELLP syndrome |
SBP>160, DBP>110
protein > 5 oliguria HELLP syndrome ONLY NEED ONE OF THESE TO BE CONSIDERED SEVERE |
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Definitive therapy for preeclampsia is?
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DELIVERY!!!!!
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Hydralazine
a) treatment for PIH b) increases CI, decreases SVR c) increases uteroplacental perfusion d) neonatal HOTN |
a) treatment for PIH
b) increases CI, decreases SVR c) increases uteroplacental perfusion d) neonatal HOTN (no severe adverse effect) |
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The top 2 reasons for morbidity & mortality r/t HTN in a pregnant woman?
a) CVA b) hemorrhage c) MI d) seizures |
#1 CVA
#2 MI |
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Which of the following cross the placenta
a) glucose b) insulin c) glucagon d) oral hypoglycemics |
ONLY glucose which is why neonates of diabetic moms have a high risk of hyperglycemia initially then a PROFOUND DROP 2 HOURS LATER!!
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In a diabetic pregnant woman
a) increased risk of hypoglycemia after delivery b) increased risk of hyperglycemia after delivery c) insulin resistance is developed |
increased risk of hypoglycemia after delivery (AFTER DELIVERY THERE IS NO MORE PLACENTA INSULINASE)
insulin resistance is developed |
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Gestational Trophoblasitc Neoplasms
a) mimic pregnancy b) produce high levels of Hcg c) hyperemesis d) hyperthyroid e) produce preeclampsia |
mimic pregnancy
produce high levels of Hcg hyperemesis hyperthyroid produce preeclampsia |
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Of the three types of Embolism which one is the ONLY one associated with DIC
a) Air b) Thrombotic c) Amniotic Fluid |
Amniotic Fluid
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Signs & symptoms of Amniotic Fluid Embolism
a) HOTN b) SOB c) pain d) pulmonary edema |
HOTN
SOB pain pulmonary edema |
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T/F Ketamine would be used in a pregnant woman with HOTN and severe hemorrhage
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TRUE, remember doses >2mg decrease placental blood flow
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Preeclampsia
a) increased risk premature birth b) risk of CVA c) alterations in lytes d) no alterations in lytes e) no decreases in Hgb, O2 |
increased risk premature birth
risk of CVA no alterations in lytes no decreases in Hgb, O2 |
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Increases of progesterone during pregnancy
a) prolong NDMR b) prolong Sux c) decrease MAC requirement d) shorten NDMR effects |
prolong NDMR
prolong Sux decrease MAC requirement |
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Magnesium sulfate
a) treatment for ecclampsia b) treatment for preeclampsia c) decreases MAC requirement d) increases MAC requirment |
treatment for preeclampsia
decreases MAC requirement |
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Peripartum cardiomyopathy
a) peak incidence right after delivery b) peak incidence 2 mths after delivery c) increases O2 demand d) peak incidence 48 hrs after delivery |
peak incidence 2 mths after delivery
increases O2 demand |
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In pt with Marfan syndrome
a) avoid HOTN b) avoid HTN |
avoid HTN
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Neonatal resuscitation
a) atropine 0.03mg/kg b) epinephrine 0.1ml/kg of 1:10,000 (0.01%) c) bicarb 1-2mEq of a 0.5mEq/ml solution d) narcan 0.1mg/kg |
atropine 0.03mg/kg
b) epinephrine 0.1ml/kg of 1:10,000 (0.01%) c) bicarb 1-2mEq of a 0.5mEq/ml solution (if prolonged resuscitation) d) narcan 0.1mg/kg (if within 4 hours of narcotic to mom and not a drug addict) |
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Fetal mortality for breech delivery
Vaginal > C-section? |
Yes!!
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MgSO4, Ntg, Hydralazine all
increase/decrease uterine blood flow |
INCREASE
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In the years from 1999-2000 the top 4 reasons pregnancy related Mortality in North Carolina were
a) Peripartum cardiomyopathy b) Obstetric hemorrhage c) Pregnancy induced HTN d) Infection e) Anesthesia complications |
#1 Peripartum cardiomyopathy
#2 Obstetric hemorrhage #3 Pregnancy induced HTN #4 Infection |
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Treatment of Peripartum Cardiomyopathy
a) preload & afterload reduction b) inotropic agents c) fluid restriction d) all of the above |
reload & afterload reduction
inotropic agents fluid restriction |
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Of the following drugs which one are OK for use in the peripartum stage
a) amlodipine b) hydralazine c) digoxin d) beta blockers e) ACEI's |
amlodipine
hydralazine beta blockers (caution as can cause IUGR) NO ACEI's or DIGOXIN!!! |
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ACEI's can cause what in fetus?
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Renal failure
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Why should anticoagulation therapy be considered in pregnant women with cardiomyopathy?
a) hypercoagulable state b) depressed ejection fraction c) stasis and turbulent flow in the dilated heart d) all of the above |
hypercoagulable state
depressed ejection fraction stasis and turbulent flow in the dilated heart |
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If medical management of peripartum cardiomyopathy is successful
a) early delivery is not required b) Vaginal delivery should be avoided c) Vaginal delivery does not have to be avoided d) passive 2nd stage delivery should be used |
early delivery is not required
Vaginal delivery does not have to be avoided |
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T/F Passive 2nd stage or assisted delivery is used to prevent complications from the valsalva maneuver when pushing.
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TRUE
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Why are vaginal deliveries preferable to C-Sections in peripartum cardiomyopathy?
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Reduced risk of endometritis, PE, and post-op complications
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T/F Combined epidural is preferred over Epidural anesthesia in peripartum cardiomyopathy
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TRUE because of lower failure rates associated with CSE and decreased PDPH
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Which pts with peripartum cardiomyopathy have a lower morbidity rate
a) higher EF b) lower EF c) smaller LVED diameters d) larger LVED diameters |
higher EF
smaller LVED diameters (so blood is not just floating around in a big sack) |
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Risk factors for placental abruption
a) cocaine b) HTN c) previous abruption d) Heavy ETOH use |
cocaine
HTN Heavy ETOH use |
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T/F 90% of abruptions are mild or moderate & without fetal distress, maternal hypotension or coagulopathy
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TRUE
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What labs would you want to be sure to draw on a pt with placenta abruption?
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Coags, CBC, T&C
THESE PTS ARE PRONE TO BLEEDING!! |
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Is there a problem with uterine atony in placenta abruption?
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Yes, possibly because blood may infiltrate the myometrium and inhibit adequate uterine contraction
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T/F all bleeding in 3rd trimester should be considered placenta previa
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TRUE
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Risk factors for placenta previa
a) multiparity b) previous C-Section c) prior previa d) scar tissue |
multiparity
previous C-Section prior previa scar tissue |
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Your patient comes in with painless vaginal bleeding in the 3rd trimester you suspect?
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placenta previa
DIAGNOSED WITH U/S |
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What is definitive treatment for placenta previa?
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DELIVERY WITH A C-SECTION!!!!
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T/F there is an increased risk for placenta acreta, increta, percreta with placenta previa
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TRUE
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With uterine rupture one risk factor is previous C-Section which type of incision is more likely to lead to rupture?
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Vertical or CLASSIC INCISION
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Symptoms of uterine rupture
a) vaginal bleeding b) severe abdominal pain/shoulder pain c) disapperance of fetal heart tones d) HOTN |
vaginal bleeding
severe abdominal pain/shoulder pain disapperance of fetal heart tones HOTN |
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T/F retained placenta is the most common cause of serious blood loss
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TRUE!!!! if the uterus does not empty completely it will NOT contract!
NEED UTERINE RELAX >1 MAC |
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In the absence of the Decidua basalis in the uterus what can this lead to?
a) placenta abruptio b) placenta accreta c) ruptured uterus d) uterine atony |
placenta accreta placenta implants directly onto or into the myometrium Separation of placenta after delivery is incomplete = HIGH BLOOD LOSS
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T/F HELLP syndrome increases risk for DIC
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TRUE
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Placental ischemia in preeclampsia could be due to?
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increase in placental thromboxane which leads to vasoconstriction, platelet aggregation and uteroplacental hypoperfusion
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CNS symptoms of preeclampsia
a) irritability b) HA c) vision changes d) hyperreflexia |
irritability
HA vision changes hyperreflexia |
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Hepatic signs of preeclampsia
a) elevated SGOT b) elevated LDH c) both of the above |
elevated SGOT
elevated LDH |
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With preeclampsia
a) GFR decreases b) GFR increases c) BUN increases d) BUN decreases |
GFR decreases
BUN increases |
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With preeclampsia
a) decreased platelets b) impaired platelet function c) DIC |
decreased platelets
impaired platelet function DIC |
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In the preeclamptic pt
a) SVR is elevated b) SVR is decreased c) CI is increased d) CI is decreased |
SVR is elevated
CI is decreased |
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Preeclamptic pts will be
a) hypovolemic b) hypervolemic |
Hypovolemic
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Definitive therapy for preeclampsia is?
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DELIVERY careful volume repletion (restoring R & L side filling pressures which normalizes CI, HR, SVR, and improves tissue and fetal perfusion)
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T/F the use of muscle relaxants in pt with preeclampsia on MgSO4 should be avoided
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FALSE, just carefully dosed!
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Placental transfer & fetal uptake of MgSO4
a) fetal hypermagnesemia b) respiratory depression c) low apgar scores d) fetal hypotonia |
fetal hypermagnesemia
respiratory depression low apgar scores fetal hypotonia |
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Labetalol and propranolol may cause what in the fetus?
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IUGR
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Esmolol
a) decrease uterine blood flow b) increase uterine blood flow c) fetal hypoxia d) late decelerations e) bradycardia f) fetal acidosis |
decrease uterine blood flow
fetal hypoxia late decelerations bradycardia fetal acidosis |
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Calcium channel blockers
a) possible teratogenic effects b) may cause uterine atony c) may cause ongoing blood loss |
possible teratogenic effects
may cause uterine atony (lack of Ca for contractions) may cause ongoing blood loss (lack of contractions) |
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T/F Nitroprusside and Nitroglycerine may be used during intubation for pregnant woman in HTN crisis
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TRUE risk of fetal cyanide toxicity and fetal wastage with large doses
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Anesthestic management of preeclamptic woman
a) vaginal delivery/C-Section b) check plt level q 6h c) regional anesthesia d) no regional anesthesia |
vaginal delivery/C-Section
check plt level q 6h regional anesthesia |
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T/F regional anesthesia may or may not result in HOTN, but will improve urinary output
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TRUE
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When would a general anesthetic be required in a pt with preeclampsia?
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Emergency, coagulopathy
REMEMBER INTUBATION MAY BE DIFFICULT DUE TO EDEMA consider smaller ETT |
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Why is a premature infant at an increased risk of intracranial hemorrhage?
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Due to soft cranial bones and fragile dura
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T/F preemies have decreased protein binding, decreased metabolism and excretion, and immature respiratory centers
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TRUE
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Gestational Trophoblastic neoplasms
a) high cardiac output from thyrotoxicosis b) pulmonary congestion from severe anemia c) PIH d) Aspiration pneumonitis |
high cardiac output from thyrotoxicosis
pulmonary congestion from severe anemia PIH Aspiration pneumonitis |
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What is the most common acquired cardiac (valve) problem ?
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Mitral Stenosis
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What is the number one congenital malformation?
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Atrial-septal defect ASD
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Fatigue, dyspnea, pulsation of neck veins, systolic murmurs occasional palpitations are
a) normal observations in a pregnant woman b) abnormal observations in a pregnant woman |
NORMAL
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Syncope, nocturnal dyspnea, HR >120, distention of neck veins, SOB at rest, diastolic murmur
a) normal observations in a pregnant woman b) abnormal observations in a pregnant woman |
ABNORMAL, A PREGNANT WOMAN DOES NOT FAINT NORMALLY!!!
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High cardiac risk factors during pregnancy
a) Pulmonary HTN b) left ventricular dysfunction c) Marfan syndrome d) cardiomyopathy (EF <40%) e) coartation of the aorta |
Pulmonary HTN
Marfan syndrome cardiomyopathy (EF <40%) coartation of the aorta |
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With cardiac disease in pregnancy preterm delivery/respiratory distress syndrome is the most common adverse neonatal outcome
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preterm delivery
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Treatment for ASD in pregnancy includes
a) optimize preload b) oxygen during labor c) avoid HOTN d) avoid tachycardia e) labor in lateral recumbent postion |
optimize preload
oxygen during labor avoid HOTN avoid tachycardia (may increase left to right shunting!) labor in lateral recumbent position |
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With Eisenmenger syndrome it is important to avoid conditions that increase __________
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PVR
metabolic acidosis hypoxemia hypercapnia vasoconstrictors |
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A woman with previous history of MI is advised to wait how long before becoming pregnant?
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at least 1 year
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With a woman who has suffered an MI during pregnancy how long is delivery attempted to be delayed?
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2-3 weeks so that will be able to handle the fluid shifts that will occur with delivery
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Mitral regurg/Mitral stenosis which one is placing an epidural OK in?
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Mitral Regurg this patient likes preload and tachycardia!
Mitral Stenosis can't handle HOTN |
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When reversing muscle relaxants why is it important to give them slowly?
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because acute increases in AcH can induce uterine contractions
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