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What increases at 12 weeks that places women in a relative metabolic alkalosis?
Spurred by increased progesterone that stimulates respiratory efforts by increasing the sensitivity of the resp. center to CO2
Blood volume for prepregnancy
Blood volume for 12 weeks
Blood volume for 20 weeks
Blood volume for Term partiurents
At how many weeks do we consider always doing a RSI on parturient women?
What is the GI prophylaxis combo we use for pregnant women?
What is the fasting gastric residual volume in both non-pregnant and early pregnant women?
Reglan 10 mg IV can decrease this by 1/2 if given 30 minutes prior to induction
CO increases by _____ % at 8 weeks
CO increases by ______ % at 20 weeks
SVR decreases by _________ % at 8 weeks
How much blood loss can a typical early-pregnant women tolerate?
What is the greatest risk during emergent cerclage?
rupture of membranes
what induction agent is the best choice if hyperthyroid and hemorrhage is present?
What is the leading cause of maternal death in the 1st trimester?
Ruptured ectopic pregnancy
Accounts for 6% of all pregnancy related deaths
Hemorrhage is #1 for all pregnancy related deaths
What are the complications that can occur with molar pregnancy?
- A) Hyperemesis gravidarium
- B) Gestational HTN
- C) Preeclampsia
- D) Amemia
- E) Thyrotoxicosis
What are the possible sequale of ectopic pregnancy?
- recurrent ectopic pregnancy
Define ectopic pregnancy
the fertilized ovum implants outside the endometrial lining of the uterus
Name three of the eleven factors that increase the risk of an ectopic pregnancy
- 1) prior ectopic pregnancy
- 2) Prior tubal surgery
- 3) PID
- 4) Previous pelvic or abd. surgery
- 5) use of and IUD
- 6) delayed ovulation
- 7) Hormonal changes associated with a progesterone only OC
- 8) Smoking, vaginal douching
- 9) History of infertility
- 10) Assisted reproductive technology
- 11) congenital anatomic distortion
What percentage of ectopic pregnancies are tubal?
Name some signs of rupture or impending rupture of ectopic pregnancy
- Very intense pelvic pain
- delayed menses
- Vaginal bleeding
- urge to poop
- shoulder pain from increased abdominal pressure
Why is hemoperitoneum a big deal?
- Some patients can maintain stable hemodynamic status despite the accumulation of 1000-1500 ml in the cul-de-sac
- Push induction drugs and BOOM! No blood pressure
What drugs is used for the medical management of ectopic pregnancies?
Inhibits the growth of trophoblastic cells. The body then reabsorbs the cells.
What are the criteria for successful use of methotrexate in ectopic pregnancy?
- no cardiac activity
- diameter < 4cm
- no evidence of rupture
What surgical interventions may be preformed for tubal pregnancy?
Why is cervical hemorrhage such a big deal?
The cervix cannot contract
What is done if abdominal pregnancy is found?
laparotomy and delivery of fetus
uterine bleeding without cervical dilation before 20 weeks.
Bleeding may be accompanied by backache and cramping
cervical dilation or ROM without expulsion of fetus
Infection is a frequent complication
Complete, spontaneous expulsion of fetus and placenta
- partial expulsion of uterine contents. Persistant bleeding and cramping after expulsion are s&s.
- Usually required D&C
- Pitocin and methergine should be availiable
- fetal death goes unrecognized for several weeks
- DIC may occur with advanced gestational age
3 or more consecutive spontaneous abortions.
a pregnancy loss or termination either before 20 weeks or when the fetus weighs < 500 grams
Complications of suction D&C
- cervical laceration
- uterine perforation
- retained products of pregnancy
- vasovagal events
- postabortal syndrome
What should be given for patients undergoing abortion, despite the type?
Rhogam to prevent Rh sensitization
intrauterine blood clots with uterine atony associated with lower abdominal pain, tachycardia, and diaphoresis
What is the most painful part of D&C?
Cervical dilation if it is not already dilated.
- If the cervix is already dilated, sedation with or without paracervical block is usually fine.
- If it is not dilated, paracervical block, spinal or epidural, or general anesthesia should be considered.
What can occur with cervical dilation?
(The vasovagal event associated with D&C)
Incompetent cervix can be treated by _______ to help hold the fetus in the uterus until 37-39 weeks to improve survival.
Fetal survival is increased from ___ to ___% by cervical cerclage
20% to 89%
Name a few etiologies for the development of incompetent cervix
- Cervical trauma (previous vaginal delivery, D&C, conization of cervix)
- Congenital abnormalities
- intrauterine infection
- deficiencies in cervical collagen and elastin
- hormonal abnormalities
What are the contraindications for cervical cerclage?
- Preterm labor
- vaginal bleeding
- fetal abnormalities
- fetal death
- placental abruption
What sensory level should be sought for spinal/epidural for cervical cerclage?
- cervix (T10-L1)
- Vagina (S2-S4)
Partial hydatiform mole
usually have complete trisomy (one set maternal)
Complete hydatiform mole
derived solely from paternal chromosomes
presents with vaginal bleeding after delayed menses. No fetal heart rate, uterus large for gestational age, and really elevated beta-HCG (>100,000 mIU/mL)
When does acute cardiopulmonary distress usually manifest in molar pregnancies if it happens?
after uterine evacuation
Occurs in 27% of patients with molar pregnancies
Which is better for use with a patient with a molar pregnancy? Volatile or IV maintence agents?
- Because volatile agents are uterine vasodilators and can increase the potential for major blood loss during evacuation of the uterus.
Pitocin, methergin, and hemabate need to be immediately available. However, Pitocin may not work as well in early pregnancy b/c there is a lower # of Pitocin receptors
persistent form of nausea and vomiting
maybe associated with multiple gestation, thyrotoxicosis, and or GTD
Hepatitis, cholecystitis, pancreatitis, pyelonephritis, and partial bowel obstruction should be ruled out.
What are the requirements for elective induction of labor?
- Had a baby before
- singleton in vertex presentation
- at least 39 weeks
- favorable cervix
- no contraindications to L&D
What is lamineria?
Sea weed on a stick used to expand the cervix slowly without inducing labor
What are the requirements for indicated labor induction?
- Mom preeclamptic
- Post term pregnancy (>40weeks)
Criteria for diagnosis of preterm labor
- 20-37 weeks
- at least 4 documented uterine contractions in 20 minutes or 8 in 60 minutes
- Cervical dilation of greater or equal to 2 cm
- Cervical effacement of 80% or greater
PROM (premature rupture of membranes)
rupture of fetal membranes (chorioamnion) before onset of labor
Is the precipitating factor in 1/3 of preterm deliveries.
If PROM occurs during 2nd trimester, risk of pulmonary hypoplasia and orthopedic deformities increases
How is PROM confirmed?
Fern and nitrazine testing
Which antibiotics are indicated for chorioamniontis?
ampicillin and gentamicin
oxytocin and close observation of mom and fetus are also indicated
How long can tocolytic therapy be expected to prolong pregnancy?
Not past 2-7 days
Can facilitate transfer to different facility or chance to give steroids to speed fetal lung maturity and ABX to reduce group B streptococcal infection of the fetus
What are the three criteria for the use of tocolytic therapy?
Reassuring fetal status
no clinical signs of infection
Name 3 classes and an additional agent used for tocolytic therapy
- 1. Beta-adrenergic agonists (ritodrine, terbutaline)
- 2. Prostaglandin synthetase inhibitors (indomethacin)
- 3. Calcium entry blockers (nifedipine)
- 4. Magnesium Sulfate
Beta-adrenergic agonists used for tocolytic therapy
ritodrine- not available in US
Terbutaline- high incidence of maternal and fetal SE
Prostaglandin synthatase inhibitor
Calcium channel entry blocker
Terbutaline SE for mom and baby
MOM: hypotension/tachycardia, pulmonary edema, atrial and ventricular arrhythmias, anxiety/nervousness, N/V, HA, hyperglycemia, metabolic acidosis, potassium distrubances
Baby: tachycardia, hypoglycemia, increased free fatty acids, fetal asphyxia from mom hypotension, decreased incidence of respiratory distress syndrome
Magnesium Sulfate Side effects for mom
- pulmonary edema
- chest pain/tightness
- blurred vision
- Increased sensitivity to muscle relaxants
Magnesium Sulfate side effects for baby
- decreased gastric motility
What mag. serum levels are usually sufficient to inhibit uterine contractions?
What is the only identified side effect of nifedipine for the fetus?
What can happen to the fetus with indomethacin use?
Premature closing of ductus arteriosus in utero
What is the most common respiratory disease in women of childbearing age?
6% of all pregnancies complicated with asthma
Severe asthma patients tend to have more pronounced exacerbations during pregnancy
What co-mortalities are associated with asthmatic pregnancies?
- pregnancy induced HTN
- perinatal mortality
- low birth weight
- neonatal hypoxia
These are particularly seen in steroid dependent asthmatics
Prostaglandins and asthma can be good and bad because:
- Increased production of bronchodilating prostaglandins
- Increased production of bronchoconstricting prostaglandins (F-2 alpha)
What percent of women who smoke continue to smoke during pregnancy?
Name 2 long acting beta-2 agonists that are used for moderate persisitant asthma
Remember these drugs can prolong labor...
Drugs associated with exacerbation of asthma
- non- beta 1 selective antagonists (labetalol, propranolol)
- Non-beta 1 selective ophthalmic (timolol)
- Prostaglandin F-2 alpha (hemabate is a form of prostaglandin)
- Ergot alkaloids
- Sulfiting agents (Leafgreen is put on salad bars to keep the salad green and can precipitate an exacerbation)
During labor and delivery, what is the management game plan for the asthmatic patient?
Short acting and rapid onset beta-2 agonists like albuterol and steroids (corticosteroids)
What drugs do we use for mild & intermittent asthma in the pregnant patient?
short acting beta agonists (albuterol)
anti-inflammatory (inhaled steroid)
Sustained release theophylline
What drugs do we use for moderate persistent asthma?
Long acting beta 2 agonists (terbutaline and ritodrine, salmeterol)
Intensification of inhaled steroid treatment
What drugs do we use for severe persistent asthma in the pregnant patient?
Addition of systemic steroid to
Long acting beta 2 agonists
What history in a pregnant asthmatic patient would prompt you to be more aggressive in pain and stress management strategies during labor and delivery?
In women who describe asthmatic episodes triggered by exercise or stress
What is status asthmaticus?
Severe bronchospasm unresponsive to intensive beta-2 agonists and systemic corticosteroids.
May require ventilator support with volatile agents to break the constriction. Methylxanthines, anticholinergics, sedation and muscle relaxant may be necessary
What does severe bronchospasm do to intrathoracic pressure?
Increases, which may compromise CO=poor uteroplacental flow
When are asthma exacerbations more likely to occur?
- post C-section= 41%
- post vaginal delivery=4%
What is the sensory goal for C-section spinal or epidural?
Care must be taken to not get the block too high because of accessory muscle use in asthmatic patients
Which is associated with lower incidence of bronchospasm in the asthmatic patient? Regional or general anesthesia?
HOWEVER, regional is not always appropriate d/t breathing muscle weakness that can occur BUT it is the preferred method for analgesia and anesthesia
Why may pregnant patients with asthma have a higher risk of bronchospasm with RSI?
They may not be deep enough yet in the course of the induction sequence
Why is propofol a good choice for use in induction of asthmatic patients?
- It has airway responsiveness blunting properties
- Weak bronchodilating action
Why do we avoid cisatricurium, mivacron, morphine, and possible succinylcholine in the pregnant asthmatic patient?
How would you extubate a pregnant asthmatic patient?
Consider this: Cannot deep extubate b/c full stomach risk of aspiration precautions
- High narcotic technique (not morphine!)
- LTA kit
- Lidocaine 1mg/kg IV bolus prior to extubation
- Extubate immediately after stage 2
- Albuterol treatment immediately before extubation
- Decadron IV
Leave her intubated if cannot extubate safely
What other two conditions are associated with asthma?
Preeclampsia and Hypertension
What medications do we need to avoid in patients with preeclampsia, HTN, and asthma?
What morbidities are diabetic pregnant patients at higher risk for?
- Preterm labor
- fetal macrosomia
What are diabetics with associated hypertension and neuropathy at a higher risk for developing?
Because of low oncotic pressure and Left ventricular dysfunction. Low oncotic pressure caused by nephropathy from long-term kidney damage
What neonate morbidity is associated with diabetic moms?
Major congenital anomalies
Intrauterine fetal distress
- Respiratory distress syndrome
- birth trauma
- neonatal hypoglycemia
Why is the baby less acidotic with the mom receives epidural anesthesia?
Because reduced endogenous catecholamine release during labor=better uterine blood flow=fetus no hypercarbia
How do insulin requirements during labor change?
First stage= decrease
Second stage= increase
Fetuses of diabetic mothers are more susceptible to ______ associated with hypotension than non-diabetic moms.
What is DKA associated with in diabetic pregnant ladies?
beta-adrenergic agonist therapy
Decreased caloric intake
Poor medical management
What morbidities are hyperthyroid pregnant patients associated with?
- Increased rates of spontaneous abortion
- Preterm delivery
- Congenital goiter
Why is hypothryroidism not seen much in pregnancy?
Hypothyroid patients have decreased fertility
Fix the thyroid and fertile myrtle is in business
Causes of seizures during pregnancy
- head trauma
- metabolic disorders (uremia, hypoglycemia, electrolyte abnormalities, hepatic failure, subtherapeutic drug levels)
- drug/etoh withdrawal
- drug OD
- AV malformation
- brain tumor
What do decreased estrogen levels do to the seizure threshold?
What do increased estrogen levels do to the seizure threshold?
Should you avoid or try to obtain hyperventilation in the seizure prone pregnant patient?
Avoid. Hyperventilation decreases carbon dioxide levels, which can actually lower the seizure threshold and make seizures more likely to happen
What vitamin is recommended for supplementation in patients taking medications for seizure management?
Seizure drugs depress PT and Factors V and VII
What are the vitamin K dependent coagulation factors?
2, 7, 9, and 10
If you have to do a general anesthetic on a pregnant patient who has seizures, what drugs should you avoid using?
They may lower the seizure threshold
- Vascular changes are often seen with this
- What you see on the outside is also on the inside
- Hemorrhage can occur into the lesions themselves
- High Risk
- Renovasular HTN often seen by 20 years old
What are the two identified associated pathologies with neurofibromatosis?
Coarctation of the aorta
Labile HTN may indicate phyeochromocytoma or renal vascular disease
What is the hormone that increases 10 fold during pregnancy and can lead to low back pain/inability to walk?
Can we place an epidural or do a spinal if the patient has screws and rods in their back?
NO! Not gonna do it!
prolonged contraction of certain muscles after stimulation followed by a delay in relaxation
Avoid succinylcholine, cold. May consider treating patient like they have MH
Patient will be extremely sensitive to IV induction drugs
ascending paralysis that is acute and is r/t inflammatory demyelinating disease with axonal degeneration of peripheral nerves
Paraylsis is usually symmetric
Recovery in about 6 months
What disorders mimics gullian-barre syndrome?
Vitamin B deficiency associated with hyperemesis gravidarium
Poisoning with lead or other heavy metals
A group of rare disorders passed down thru families in which an important part of hemoglobin (heme) is not made properly
MS in the CNS
Demyelinating disease of CNS
No anesthetic considerations for this disease
Weakness and easy fatigability
most often affects oculomotor,facial, pharyngeal, and respiratory muscles
Avoid NDMB b/c need for reversal= reversal of anticholinesterase therapy
What can a mag. sulfate infusion do to a patient with myasthenia gravis?
Respiratory insuffiency d/t neuromuscular blocking by magnesium sensitivity
Myasthenic crisis occurs from too _____ anticholinesterase
Really weak b/c not enough AcH in neuromuscular junction
Cholinergic crisis occurs from too ______ anticholinesterase
Cholinergic crisis is excessive tearing, hypersalivation, bradycardia, sweating, abdominal cramping, diarrhea. PNS going wild.
what medication can be used to distinguish myasthenic crisis from cholinergic crisis?
Symptoms improve= more anticholinergic meds needed (myasthenic)
symptoms do not improve= cholinergic crisis is present
What is the preferred reversal agent (if you have to pick one) for Myasthenia gravis patients?
What are the anesthetic considerations for patients with myasthenia gravis?
- Use opioids with caution
- regional is recommended
- decreased dose of non-depolarizers
- succinylcholine DOA can increase to 90 minutes
- Vasodilation above the lesion (red shirt)
- Vasoconstriction below the lesion (white pants)
Bradycardia and uterine constriction= poor placental perfusion
Expect if lesion T6 or higher. Consider regional for any patient with a T7 or higher injury.
At what level of spinal cord damage can we expect labor pains to be absent?
If a patient presents with Post dural puncture headache, what should we also evaluate for?
Arnold chiari syndrome
What is the most common cause of dwarfism?
- Small thoracic cage=decreased FRC
- Difficult intubation should be anticipated
- Smaller dose of spinal/epidural anesthetic d/t short stature
Genetic defect for type 1 collagen
- inability to hyperextend neck
- BP cuff or tourniquets could break the bones
- Platelet dysfunctin=modest bleeding tendency
Is the presence of an AVM an absolute contraindication for epidural/spinal?
No. AVMs may have a cutaneous angioma warning of the area, so assessment and planning can make this procedure happen. If while doing an epi/spinal and see pulsatile flow, you need to pull out and go to MRI immediately
Primary hemostasis is
monitored by platelet count and bleeding time
results in fibrin clotting and consists of the extrinsic pathway, intrinsic pathway, and the final common pathway of coagulation
Where are all the clotting factors formed except for factor 8?
Describe the guildelines for regional anesthesia in patients receiving LMWH
The needle can be placed or removed after 10-12 hours after the last dose of lovenox
Wait to give the LMWH until 2 hours after the catheter has been removed.
What reverses heparin?
Protamine sulfate. Salmon sperm.
What two clotting factors are at play with von Willebrand's Disease?
Factor 8 and von Willebrand factor
What do you give for von Willebrand disease patients?
DDAVP. If unresponsive, then give FFP or cryopricipate
What is the dose of FFP and vitamin K to give for liver disease patients?
10-20 ml/kg FFP
50 mg IM vitamin K
What are the two leading causes of death in pregnant patients with sickle cell disease?
When is the most dangerous time for CV pregnant patients?
Right after birth
Contractions can be detrimental for the CV patient because
auto-transfusion from the uterus
What is one of the leading causes of heart valve diseases?
Rheumatic heart disease
Usually with mitral valve
With stenotic valve disease of the heart, do we want to try and increase the HR and BP substantially over normal?
No. If the flow is slow, we want to keep it slow. Maintain HR. Avoid tachycardia causing drugs.
If you need to increase the BP on pregnant patients with valve problems, what can you do?
Left uterine displacement
DO NOT open fluids up wide. Fluid overload is a big problem
With valve regurg, is it ok to promote faster flow?
Yes. A little tachycardia to promote forward flow is good.
- Elevated liver (enzymes)
- Low Platelets
- of malaise, epigastric pain, nausea and vomiting, nonspecific flulike syndrome
- and proteinuria may be very mild, progressing rapidly
- of DIC as well as liver and renal failure
Which direction does the oxygen hemoglobin dissociation curve shift in HELLP patients?
To the left.
•Effective anticonvulsant, tocolytic and mild vasodilator
- of choice for seizure prophylaxis
- Competes with calcium at the cell
- membrane level and prevents an increase in free intracellular calcium
Normal plasma level for Magnesium
1.5 - 2
Therapeutic range for Magnesium therapy
EKG changes associated with Magnesium Serum level of
Loss of reflexes is associated with a Magnesium level of ?
What is seen with magnesium levels of 15?
SA and AV node blocks
What is seen with a magnesium level of 25?
Cardiac arrest :(
How do you treat magnesium overdose, and what other signs are noted with OD?
Loss of deep tendon reflexes
PQ interval prolonged, QRS widen
- Mg overdose – 1g (10 ml) 10% calcium gluconate over 2 minutes, OR 300 mg calcium chloride.
- Give bicarb if metabolic acidemia
- is suspected.
Sensitivity to nondepolarizers increased in parturients receiving Mg++ and reversal at end of procedure may be prolonged, so cautious dosing is appropriate. (Think about MG)
Which two prostaglandins are in imbalance in mom when she is preeclamptic?
Thromboxane A2 -
- •Thrombaxane in excess is associated
- with vasoconstriction, platelet aggregation, ↓
- UBF and ↑ uterine activity
Prostacyclin- antithesis to thromboxane
Why is preeclampsia such a big deal?
- During a normal pregnancy, trophoblastic invastion into the spiral arteries occurs twice,
- once before 12 weeks gestation and again at 14-16 wks gestation. In preeclampsia this
- secondary invasion does not occur, leading to placental ischemia and vascular endothelial injury. This leads to vasoconstriction, decreased renal blood flow and GFR, increased platelet
- aggregation and increased liver enzymes.
- Normally, you have a high volume, low pressure system in the uteroplacental area.
- With preeclampsia, this becomes a high pressure, low flow system leading to placental hypoperfusion.
- This occurs in the 16-18th week due to the trophoblasts not completing their second phase.
The uterine arteries are in a generalized vasoconstricted state. It is a physiological issue. IUGR babies can result because of the decreased blood flow.
- hypertension with renal involvement
- proteinuria > 300mg/24 hours
Hypertension with renal AND CNS involvement
What is the time cut off for gestational hypertension?
> 20 weeks
What is the definitive treatment for preeclampsia?
Delivery of fetus and placenta
What is the hallmark of preeclampsia?
- vasospasm that occurs secondary to increased circulating levels of renin, aldosterone, angiotensin and catecholomines.
- Aldosterone also causes sodium and water retention. Almost every organ system is involved.