Ob - dr thomas

Ob

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1. Dr Ushma Thomas OB ANESTHESIOLOGY
2. Which of the following antihypertensive medications is considered a FIRST-LINE treatment for management of severe hypertension in women with preeclampsia? • A. Nicardipine • B. Diltiazem • C. Enalapril • D. Hydralazine
3. Hypertensive Disorders in Pregnancy • Gestational Hypertension • Preeclampsia • Preeclampsia without severe features • Severe Preeclampsia • Chronic Hypertension • Chronic Hypertension with superimposed preeclampsia
4. Preeclampsia • Defined as new onset hypertension and proteinurea after 20 weeks gestation • Preeclampsia without Severe Features Blood pressure greater than or equal to 140/90 mm Hg Proteinuria (greater than or equal to 300 mg/24 h, protein- creatinine ratio greater than or equal to 0.3, or 1+ or greater on urine dipstick specimen) • Severe Preeclampsia Blood pressure greater than or equal to 160/110 mm Hg Thrombocytopenia (platelet count less than 100,000/mm 3 ) Serum creatinine concentration greater than 1.1 mg/dL or greater than 2 times the baseline serum creatinine concentration Pulmonary edema New-onset cerebral or visual disturbances Impaired liver function
5. Management • Delivery remains the only “cure”-recommended for women presenting with preeclampsia with severe features at 34 weeks gestation or later. If less than 34 weeks, expectant management may improve fetal outcomes however limited data. At least delay 24-48 hours to allow administration of steroids or if mom has refractory htn despite max doses of medication or persistent cerebral symptoms while on mag therapy. • Admission labs: CBC (mainly plts), coags, CMP, LFTs and assess for symptoms. Plt count less than 100K on admission, then should be concerned for coagulopathy (PT, PTT, INR, and fibronogen) and reassess plt count every 6 hours. T+S/T+C should be available • Even though associated with intravascular volume depletion, there is insufficient evidence to support volume expansion. Fluids should be limited and fluid challenges only given in oliguric patients if volume deficit is suspected or can be confirmed.
6. • Antihypertensive medications: • Used to treat severe HTN (>=160/>=110) • Carefully titrate to avoid abrupt changes to fetal perfusion • Goal: lower MAP by 15-25% with a target SBP 120-160 and a DBP 80-105 mmHg • First line agents: labetalol, hydralazine, and nifedipine • Nicardipine and esmolol are second line agents. Seizure prophylaxis with Mg. Therapeutic range is between 5-9 mg/dL. Reflex testing is used as a clinical screen for hypermagnesemia. Patellar reflexes are lost at ~12, respiratory arrest at 15-20, an asystole >25 mg/dL. Should consider serial measurements in women with renal dysfunction as Mg is renally excreted.
7. Which of the following solutions applied to the skin is nonflammable? • A. Benzoin • B. Betadine • C. Chlorhexadine • D. Mastisol
8. Skin Prep solutions and OR safety • It is important to recognize that many commonly used skin preparations, such as chlorhexadine, benzoin, and Mastisol, contain alcohol and are flammable. Betadine is alcohol free and nonflammable. • Betadine should always be used for skin prep in emergent procedures such as a STAT C/S where there is no time to wait the full 3 minutes for the solution to dry before using electrocautery.
9. A 23 year old woman suffers an unintentional dural puncture during placement of a labor epidural and subsequently experiences a postdural puncture headache. Which of the following actions is indicated PRIOR to performing an epidural blood patch? • A. Assess for fever • B. Obtain CT lumbar spine • C. Obtain a CBC to check for leukocytosis • D. Nothing-place epidural blood patch
10. Postdural Puncture Headache • PDPH can occur after intentional dural puncture with a spinal needle or unintentional dural puncture with an epidural or other needle. • Always perform a thorough history and physical prior to placing an EBP. Specifically, look for signs of maternal systemic infection, coagulation status, and any other alternative diagnosis to a PDPH which could change management.
11. A 27 year old woman undergoes a primary cesarean delivery under spinal anesthesia with bupivacaine, fentanyl, and morphine. After arriving in the PACU she starts to complain of severe pruritis. What is the etiology of her pruritis? • A. Histamine release • B. Mu- receptor • C. Kappa receptor • D. GABA receptor
12. Opioid induced pruritis • Most common side effect of epidural or intrathecal opioid administration. (Intrathecal>>Epidural) • Incidence and severity are dose related. • The cause is poorly understood but it appears to be mediated through central Mu-opioid receptors. • The most effective treatment is a centrally acting Mu opioid antagonist (naloxone or naltrexone) or a partial agonist-antagonist such as nalbuphine. • Must be mindful of reversing the analgesic effect when using a continuous infusion or large bolus doses.
13. Which of the following tocolytic drugs has the fewest MATERNAL side effects? • A. Nifedipine • B. Terbutaline • C. Magnesium Sulfate • D. Indomethacin
14. Side effects of commonly used tocolytics CCB- Maternal: transient hypotension, flushing, headache, dizziness, nausea. Fetal: none NSAIDs: maternal: nausea, heartburn fetal: constriction of the ductus arteriosus, pulm HTN, reversible renal dysfunction, IVH, hyperbilirubinemia, NEC Beta-adrenergic receptor agonists Maternal: dysrhythmias, pulmonary edema, myocardial ischemia, hypotension, tachycardia, hyperglycemia, hyperinsulinemia, hypokalemia, antidiuresis, altered thyroid function Fetal: tachycardia, hyperinsulinemia, hyperglycemia, myocardial and septal hypertrophy, MI Magnesium: Maternal: flushing, lethargy, headache, muscle weakness, diplopia, pulmonary edema, cardiac arrest Fetal: lethargy, hypotonia, respiratory depression
15. A 29 yo female undergoing a vaginal delivery complains of shortness of breath immediately leading to hemodynamic collapse. She is emergently intubated and started on vasopressor support. Which of the following would be MOST consistent with a diagnosis of amniotic fluid embolism? A. Right heart strain seen on TEE B. Plt count of 75K C. INR of 1.8 D. Fibrinogen of 130
16. Amniotic Fluid Embolus • AFE is a rare obstetric emergency classically presenting with respiratory distress, cardiovascular collapse, disseminated intravascular coagulopathy (DIC), or coagulopathy and seizure or coma. • The definition includes 4 elements: Sudden onset of cardiorespiratory arrest or hypotension with respiratory compromise DIC following cardiovascular collapse, but prior to development of hemorrhage Clinical onset of labor or temporally 30 minutes within delivery of placenta Absence of fever (38°C) during labor • Classically, reports of fetal cells or fetal antigens in postmortem evaluation of maternal pulmonary vasculature has been used to confirm the diagnosis of AFE. However, AFE is a clinical diagnosis. • Recently, the SMFM published clinical guidelines regarding the diagnosis and management of AFE based on a systematic literature review. Management for suspected AFE includes early suspicion, especially in any patient who experiences sudden cardiovascular collapse or has immediate evidence of DIC. • Treatment involves immediate delivery of the fetus, provision of adequate oxygenation, ventilation and circulatory support and early assessment of clotting status and correction via massive transfusion protocols.
17. and delivery floor with painful contractions. She is expected to have a vaginal delivery. She is noted to be on buprenorphine therapy for history of chronic pain. Which of the following is true? • A. Buprenorphine is a partial antagonist at the µ-opioid receptor and an agonist at the κ-opioid receptor • B. She should not breastfeed for at least 72 hours after her last dose. • C. She should hold her dose for that morning and be placed on an IV PCA for pain. • D. The primary analgesic modality for managing labor and vaginal delivery analgesia for women receiving buprenorphine is regional analgesia/anesthesia.
18. Buprenorphine in the Parturient • Used to treat both chronic pain and opioid abuse, it is a partial agonist at the µ-opioid receptor and an antagonist at the κ-opioid receptor. • This profile allows for a ceiling effect for respiratory depression and an improved side-effect profile . Partial µ-opioid agonism reduces the overdose risk, however the strong binding affinity to the µ-opioid receptor, combined with its action as a partial agonist, results in inadequate treatment of post–cesarean delivery. • The primary analgesic modality for managing labor and vaginal delivery analgesia for women receiving buprenorphine is regional analgesia/anesthesia. • According to ACOG, women on buprenorphine maintenance therapy should continue their maintenance therapy without a change in dose through the peripartum period. • Buprenorphine is found in the breast milk 2 hours after maternal dosing, but the overall concentration is low. Women are encouraged to continue breastfeeding.
19. A 28 yo G2P0 woman has requested an epidural for labor analgesia. Which of the following catheters is associated with the lowest incidence of epidural venous cannulation? • A. Nylon • B. Polyvinyl chloride • C. Polytetrafluoroethylene • D. Wire reinforced polyurethane
20. Epidural catheter design • Typical rigid catheters are made from nylon, polyvinyl chloride, or polytetrafluoroethylene. Soft, flexible catheters often have an inner wire reinforcement and a thin outer layer of polyurethane or nylon blend around it. • Wire-reinforced catheters represent the most recent technological advance in epidural catheter design. The inner wire coil is designed to provide strength for insertion, lumen patency, and is kink resistance. • Soft-tipped, flexible catheters are believed to result in fewer paresthesias because they curl up or change course as they brush against nerve roots or other obstacles in the epidural space. • Flexible wire-reinforced catheters have been observed to have a lower incidence of intravascular cannulation compared with conventional rigid catheters.
21. A 28 year old G1P0 woman with a history of CRPS is admitted for induction of labor at 41 weeks of gestation. When her cervical dilation is 3 cm she requests an epidural. Which of the following factors is the STRONGEST indication for epidural placement at this time? • A. history of CRPS • B. Post date pregnancy • C. Primiparity • D. patient request
22. Neuraxial Anesthesia and Outcomes of Labor • According to the 2016 Practice Guidelines for OB anesthesia, it was strongly agreed upon in uncomplicated pregnancies: • (1) provide patients in early labor (i.e., less than 5 cm dilation) the option of neuraxial analgesia when this service is available • (2) offer neuraxial analgesia on an individualized basis • (3) not withhold neuraxial analgesia on the basis of achieving an arbitrary cervical dilation. For a trial of labor after previous cesarean section: (1) offer neuraxial techniques to patients attempting vaginal birth after previous cesarean delivery (2) it is appropriate to consider early placement of a neuraxial catheter that can be used later for labor analgesia or for anesthesia in the event of operative delivery. For complicated parturients: (1) consider early insertion of a neuraxial catheter for obstetric (e.g., twin gestation or preeclampsia) or anesthetic indications (e.g., anticipated difficult airway or obesity) to reduce the need for GA if an emergent procedure becomes necessary.
23. A 35 year old non smoking woman is scheduled for a repeat cesarean section. She is refusing neuraxial anesthesia at this time. She had general anesthesia with her first cesarean section and had severe postoperative nausea and vomiting. What is her approximate risk of PONV if no prophylactic medications are given? • A. 10% • B. 20% • C. 40% • D. 60% • E. 80%
24. Postoperative Nausea and Vomiting • Risk factors for PONV include: • female sex • non-smoking status • history of PONV • postoperative use of opioids • Patients with 0, 1, 2, 3, and 4 risk factors have a risk of 10, 20, 40, 60, and 80% for PONV, respectively. • Patients with 3 or more risk factors should receive 3 or more interventions to decrease PONV using a multifaceted approach. • Additional strategies to reduce baseline risk include the following: • (1) Avoiding general anesthesia by using regional anesthesia • (2) Preferential use of propofol infusions • (3) Avoiding nitrous oxide • (4) Avoiding volatile anesthetics • (5) Minimizing perioperative opioids • (6) Adequate hydration.
25. Gestational diabetes is most commonly associated with which of the following: • Fetal shoulder dystocia • Placental abruption • Polyhydramnios • Preeclampsia