Term
| What are the 3 types of abnormal placental implantations? |
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Definition
- Placenta increta ("in"=INTO the myometrium)
- Placenta accreta ("a"=AGAINST or ONTO the myometrium)
- Placenta percreta ("per-" means "thru" as in percutaneous=thru skin. Or "p"=pierce. THRU the myometrium)
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Term
| What obstetric condition is associated abnormal implantation conditions? |
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Definition
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Term
| Two of the three implantation conditions can be diagnosed with ultrasound. Which one can not be reliably diagnosed w/ US? |
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Definition
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Term
| Which of the implantation conditions is considered the most dangerous? |
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Definition
| Placenta percreta: maternal hemorrhage and death can occur despite adequate preparation and management. |
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Term
| What is the typical sequence of events during delivery of a baby/mother with placenta percreta? |
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Definition
- Deliver baby
- Leave placenta in place
- Close the uterus to hopefully tamponade the bleeding
- Perform hysterectomy
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Term
| What's the average blood loss associated with the implantation conditions? What percentage of the pts. develop coagulopathies? What percentage require hysterectomy to stop bleeding? |
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Definition
1. 2-4000 mL
2. 20%
3. 30-70 require hysterectomy |
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Term
| Vasa previa is associated with >50% mortality. Why is this condition so dangerous? |
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Definition
| Vessels from the umbilical cord cross the cervical os prior to entering the placenta (although I think she meant to say fetus). These vessels are therefore exposed during birth and fetal decent. C-SECTION BEFORE LABOR IS IMPERATIVE WITH VASA PREVIA! |
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Term
| Umbilical Cord prolapse can rapidly lead to fetal asphyxia. What are some predisposing factors that increase the likelihood of prolapse? |
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Definition
- Really long cord
- malpresentation
- low birthweight
- grandparity (>5 pregnancies)
- multiple gestation
- artificial ROM
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Term
| What fetal signs might make me highly suspicious of cord prolapse? How might my suspicions be confirmed? |
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Definition
- Sudden fetal bradycardia or profound decelerations.
Confirmed by sticking your finger up there and feeling the cords through the cervical os.
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Term
| How is cord prolapse treated? |
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Definition
- IMMEDIATE steep trendelenburg or
- knee to chest position
- manual pushing of fetus back up into pelvis until C-section can continue under GA.
- If the fetus is not viable vaginal birth is allowed to continue
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Term
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Definition
| Difficult labor that may be due to ineffective contractions, abnormal lie, position, presentation or disproportionate pelvic-fetal dimension. |
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Term
| What are the 3 types of fetal lie? |
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Definition
Transverse
Longitudinal
Oblique |
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Term
| What does fetal presentation refer to? What two types of presentation allow for vaginal birth? |
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Definition
- Fetal presentation refers to the body part that overlies the pelvic inlet.
- Vag. deliverty can only occur with a longitudinal lie where the head (vertex) or buttocks or legs (breech) descend first.
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Term
| External versions can be used to move fetuses out of the breech position. They are successful in 75% of cases but can lead to complications such as... |
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Definition
- placental abruption
- cord compression
These conditions require immediate C-section. Therefore, its nice to have an epidural in place before attempting external version. |
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Term
| Breech deliveries can be tricky because the head can get stuck. If this happens you may need to switch to general but you can try another technique first...what is it? |
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Definition
| 50-100mcg nitroglycerine to improve uterine relaxation. This drug is preferred because it is short-acting--> less time as a floppy uterus-->less bleeding. Note: You could use phenylephrine to counteract a drop in BP associated with nitro b/c the uterine muscle doesn't have many alpha-1 receptors! |
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Term
| What type of presentation is associated with more pain for mom and a prolonged labor? |
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Definition
| persistent occiput posterior |
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Term
| If persistant occiput posterior is an abnormal presentation what direction is the baby's head normally facing during labor? |
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Definition
| Directly facing mom's cornhole! Eewwwww! |
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Term
| What are the anesthetic implication for persistent occiput posterior? |
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Definition
| None really. It just requires the use of forceps which increases risk of injury to mom and babe. |
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Term
| Preterm labor (20-37th week) is the most common complication of the 3rd trimester. What are the contributing factors? |
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Definition
- extremes age
- inadequate prenatal care
- unusual body habitus
- increased physical activity
- infection and other comorbidities
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Term
| How much do babies under the age of 30 wks typically weigh? |
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Definition
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Term
| When is surfactant production usually adequate? |
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Definition
| after 35 weeks. You can give glucocorticoids to induce production in the real youngins. |
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Term
| If the fetus is less that 35 weeks what should you be scerred about? What is done to prevent complications? |
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Definition
| Soft cranium--> intracranial hemorrhage during delivery--> Bedrest + tocolytic therapy initiated to allow for maturation (may give glucocorticoids for surfactant production) + antibiotics given until beta strep cultures are negative |
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Term
| What are the most commonly used tocolytics? |
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Definition
- Beta 2 Agonists (Ritodrine or terbutaline) - Both have some beta 1 activity with implications for increased HR, hyperglycemia, hypokalemia, arrhythmia
- Magnesium
- Calcium channel blockers
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Term
| When tocolytics fail what type of vaginal delivery to we want for premies? |
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Definition
SLOW AND CONTROLLED WITH MINIMAL PUSHING (recall the increased risk for intracranial hemorrhage). Large episiotomies are often done. Epidural, spinal or general may all be used.
If you are part of team charged with resuscitation of the premature infant remember the psychological factor (doing invasive stuff in front of mom??). |
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Term
| Multiple gestation occurs in 1 in 90 births. What are some of the physiological/potential anesthetic implications of a multiple gestation birth? |
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Definition
- Associated with breech presentation and prematurity
- 2nd baby usually more depressed or asphyxiated than the first
- increased risk of aortocaval compression
- An epidural improves pain management and research shows that it may improve 2nd baby's fetal pH.
- Overstretched uterus is more prone to bleeding and requires more pitocin to produce contraction (make sure all the little critters are out before starting pitocin!)
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Term
| PROM complicates_____of pregnancies and is responsible for_____of premature deliveries. |
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Definition
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Term
| What are the predisposing factors for PROM? |
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Definition
- short cervix
- prior hx of PROM or preterm delivery
- infection
- multiple gestations
- polyhydramnios
- smoking
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Term
| What two factors do you have to balance when determing how to handle the pregnancy affected by PROM? |
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Definition
The age of gestation (degree of prematurity if any) and risk of infection(longer you wait to deliver the greater the likelihood for chorioamnionitis and endometritis).
- usually deliver after 34 wks
- if small fetus may give abx and tocolytics to allow time for lung maturity
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Term
| You patient has PROM. What are some signs that they have choramnionitis or endometritis? If these symptoms are evident what implications may this have for anesthetic technique? |
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Definition
S/Sx: fever, elevated C-reactive protein, leukocytosis (duh, this happens with infection)
Anesthetic implication: some practitioners think that doing regional in the infected parturient increases the likelihood of meningitis (seems to be unfounded)
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Term
| Gayle lists conditions for increased incidence of fetal demise. Do your best to list them. |
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Definition
- prolonged pregnancy (>42 weeks)
- diabetes (poorly controlled)
- SLE (systemic lupus erythematosus)
- infection
- HTN
- preeclampsia
- eclampsia
- hemoglobinopathy
- old mom
- Rh disease
- Uterine rupture
- antiphospholipid syndrome
- acute/sever maternal hypotension
- maternal death (really?)
- multiple gestations
- intrauterine growth restrictions
- congenital abnormality
- infection (parvovirus, CMV, listeria)
- cord accident
- abruption
- PROM
- vasa previa
- if you read all of these you are a nerd
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Term
| A diagnosis if fetal demise is given for death of a fetus with a birth weight of _____or more and a gestation of ______or longer. Anything less is termed miscarriage. |
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Definition
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Term
| Labor is induced ASAP when fetal death is determined. What happens if the fetus is not removed? |
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Definition
When dead and left in 3-4 weeks fibrinogen levels may begin to drop, leading to coagulopathy.
This is more of a probelm with twins b/c one may die and induction of birth may be delayed to allow the living fetus to mature. In these cases perinatologists recommend checking a set of baseline coag labs at time of demise and rechecking them as needed. Overall risk of DIC is low. |
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Term
| You can organize heart disease in the parturient into 2 major categories. What are they? |
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Definition
- Heart disease where regional is good
- Heart disease where regional is bad
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Term
| List types of heart disease in which regional will benefit the parturient. |
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Definition
- Mitral valve disease
- aortic insufficiency
- congenital lesions with left to right shunting
Conditions where you want full, fast and forward. Regional reduces preload and afterload which improves pulmonary congestion. |
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Term
| List types of heart disease in which regional will be deleterious for the parturient. |
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Definition
- Aortic stenosis
- Primary pulmonary hypertension
- congenital lesions creating right to left shunts
They tolerate pudendal blocks and GA better.
Recall that patient with aortic stenosis requires a higher SVR in order to maintain a high diastolic pressure for coronary perfusion (AS limits flow through the aortic valve thus reducing volume in the aorta and systemic circulation). Regional reduces SVR and preload. |
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Term
| Tim loves triads and the triad for amnioembolism is no exception. We know Tim knows it, but do you? |
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Definition
- Hypoxia
- Hemodynamic collapse
- Coagulopathy
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Term
| Mortality for amnioemolism nears 100%. What may cause it to occur? |
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Definition
- elective abortions
- induced abortions
- amnioncentesis
- abdominal trauma
- vag and C-section delivery
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Term
| The symptoms, as opposed to the triad, for amnioembolism, are what? |
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Definition
- chills
- shivering
- anxiety
- cough
- dyspnea
- cyanosis
- tachypnea
- pulmonayr edema
- cardiovascular collapse
- quick desat
Pretty much the same as a PE but these women have to worry about DIC if they survive the initial insult. |
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