Early Pregnancy Test Questions – Flashcards
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Pharmacokinetics Changes during pregnancy & lactation (increased/decreased)
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increased: 1. mucosal and subcutaneous uptake 2. Volume of distribution 3. Elimination of Drugs due inc GFR 4. Cephalosporin and Digoxin clearance decreased: 1. GI absorption and uptake 2. plasma protein binding (more free unbound drug)
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dec & inc Cytochrome P450 isoenzymes results in
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1. increased Metabolism of Midazolam, Phenytoin, and Morphine are 2. decreased metabolism of theophylline and caffeine
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What is teratology
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Development period when the fetus is most susceptible to injury from exogenous substances (medications, toxins, etc)
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semester during pregnancy when fetus is most vulnerable to teratogens
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1st Trimester is critical development period
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Teratogenic Drugs: Benzodiazepines
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Diazepam: Cleft palate, Neural tube defects Midazolam not teratogenic??
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Teratogenic Drugs: tetracyclines
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dental enamel stains, bone deformities in children
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Teratogenic Drugs
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tetracycline diazepam Quinolones (Ciprofloxacin, Norfloxacin) Warfarin Phenytoin, Phenobarbital, Valproic Acid, and Carbamazepine ACE inhibitors and Amiodarone
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what is the Drug safety during Lactation
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* Most anesthetic drugs are safe and short-acting * 1-2% of maternal exposure appears in breast milk- "First pump then dump" after general anesthesia.
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Does codeine appears in breast milk?
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- Codeine can be converted to morphine leading to profound neonatal depression in some mothers (rapid metabolizers). - pump & dump breast milk
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Complications of Early Pregnancy
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1. Ectopic Pregnancy 2. cervical incompetency
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what is ectopic pregnancy
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- Fertilized egg implants outside the uterus - 16 in 1000 pregnancies
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leading cause of pregnancy -related death during 1st trimester.
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Ruptured ectopic pregnancy
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Clinical Presentation ectopic pregnancy
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1. Subtle initial signs 2. Abdominal or pelvic pain 3. Delayed menses 4. Vaginal Bleeding followed by pain 5. Tender adenexal mass 6. Can have Hemoperitoneum (1000-1500 ml) without signs or symptoms
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Medical (Conservative) 50% resolution ectopic pregnancy
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Methotrexate Close monitoring of beta HCG levels
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Surgical ectopic pregnancy
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1. Diagnostic Laparoscopy 2. Tubal ectopic may require fallopian tube removal 3. Laparotomy if bleeding is extensive and associated with hemodynamic instability
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T/F it is easy Preserving fertility with ectopic pregnancy
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Preserving fertility may be challenging
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what is Cervical Incompetency
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- Inability for the cervix to sustain pregnancy to term due to inherent or traumatic deficiency - 4.4 per 1000 live births
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Causes of cervical Incompetency
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cervical trauma, congenital abnormalities, intrauterine infection, deficiency in cervical collagen and elastin, or hormonal abnormalities
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surgical management of cervical Incompetency
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Cerclage- ligature tied around the cervix to close the opening
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Anesthesia Management during early pregnancy
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Spinal 1. 7.5 mg bupivacaine or Lidocaine 50 mg 2. T10-S4 block 2. LUD if > 18 weeks
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Anesthesia Management during early pregnancy If uterine relaxation is needed
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GETA with full stomach precautions if > 18 weeks gestation
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Anesthesia Management during early pregnancy
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Avoid large increases in intra-abdominal pressures (coughing, N/V, etc)
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Clinical Presentation intrauterine fetal demise
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Symptoms include cramping, uterine bleeding, and/or backache see more slide 14
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Abortion and Intrauterine Fetal Demise r/t
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1. Pregnancy loss or termination before 20 weeks gestation or fetal weight < 500 gm. 2. Spontaneous (10-15% of all pregnancies) 3. elective
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Abortion and Intrauterine Fetal Demise Management
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1. Prostaglandins 2. Dilation and Uterine Suction Curettage
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What to consider during D&C
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1. Is the cervix dilated or closed? 2. Anesthetic technique: GETA, spinal (more common), or epidural 3. Rh antigen screen (RhoGAM post-operatively if mother is Rh negative) Watch for large blood losss
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why is important draw Rh antigen test
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Avoids future pregnancy related hemolytic newborn disease if mother is Rh negative
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how to prevent bleeding during D&C
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1. Large bore IV, T & C match/screen 2. Minimize MAC in GETA (causes uterine atony and additional bleeding) 3. Use of uterotonics
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name Uterotonic Drugs use in D & C
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1. Oxytocin 20-40 u/liter for persistent uterine relaxation 2. If bleeding continues use a stronger uterotonic: --Methergine --Hemabate (synthetic prostaglandin)
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Methergine (drug info)
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(methylergonovine) GIVE IM 0.2 mg, can cause severe HTN. AVOID IV ADMINISTRATION.
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Hemabate (drug info)
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(15 Methylprostagladin) GIVE IM 0.25 less HTN than Methergine, but can cause bronchospasm and contraindicated in asthma patients
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Intrauterine Fetal Demise (IUFD) > 20 weeks gestation
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1. 90% of women will go into labor within 2 weeks of fetal death 2. Disseminated intravascular coagulation occurs in 20-25% of women with IUFD if fetus is not delivered with 2-3 weeks 3. ***Multigestational ethical considerations ---Monochorionic twins 1 placenta ---Dizygous 2 placenta
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Intrauterine Fetal Demise (Causes)
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slide 18
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Management Options IUFD
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1. D & C - Dependent fetal size and gestational age 2. Oxytocin/prostagladin induction with a planned delivery 3. Epidural pain management 4. IV analgesia and sedation often indicated 5. Proper communication with all hospital staff 6. Psychological and spiritual counselors made available if requested
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Nonobstetric Surgery during Pregnancy
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1. Higher rates of spontaneous abortion 2. Preterm delivery 3. Etiology unknown
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Nonobstetric Surgery during Pregnancy: Considerations
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1. Teratogenicity of drugs (Already discussed) 2. Derangement of maternal physiology that may effect the fetus (teratogenic factors) 3. Diagnostic Procedures: Exposure to radiation. -- Dose (Duration), type, and timing during gestation
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name the Derangement of maternal physiology that may effect the fetus (teratogenic factors) during non obstetric surgery
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- Maternal hyperthermia - Hypotension, hypoxemia, hypercapnia
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Anesthetic Management non obstetric surgery
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1. Prevention of Preterm Labor 2. Elective surgery should NOT be done during pregnancy. 3. Delay surgery until the 2nd trimester minimizes fetal complications. 4. In life threatening emergencies, the mother's wellness comes first. 5. Risk of appendicitis and peritonitis are increased with pregnancy.*
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T/F CABG, Liver transplantations, and induced hypotension cases have all been done with successful neonatal outcomes.
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True
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Decision to perform a simultaneous C-section is dependent on these factors.
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1. Gestational age (>24 weeks preferable) 2. Risk to the mother for a trial of labor before surgery 3. The presence of intra-abdominal sepsis 4. The fetus is usually delivered first, then the surgery is performed.
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reasons why diagnosis of Abdominal Emergencies during Pregnancy maybe difficult due to:
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1. Maternal leukocytosis already exists 2. Common symptoms of constipation, N/V, and abdominal distention are normal in pregnancy 3. Abdominal tenderness may indistguishable from ligamentous or uterine contraction pain 4. Physical examination is difficult (enlarged uterus) 5. Caution to perform normal diagnostic imaging because of fetal radiation exposure
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Common Abdominal Problems during Pregnancy
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slide 24
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Laparoscopic Guidelines During Pregnancy
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1. laparoscopy can safely performed during any trimester of pregnancy 2. thromboguards should be use intra-op & post-op for DVT prophylaxis 3. fetal heart rate & tone monitored & documented pre & post-op 4. left uterine displacement should be maintained to avoid aortacaval compression 5. low pneumoperitoneum pressure (bet 10-15 mmhg) should be used.
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T/F tocolytic agents (terbutaline) should be used prophylactically
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false
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Anesthetic Management
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1. Acid aspiration prophylaxis >18 wks- Bicitra, reglan, and histamine blocker 2. Regional is preferred (less fetal exposure to anesthetic agents) 3. No difference in outcomes between GA vs regional 4. Left uterine displacement after 18 weeks 5. Rapid Sequence intubation > 18 weeks and GA required
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is it safe to perform DC cardioversion on pregnant patient
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1. safe in all stages of pregnancy) 2. Small amount current reaches the fetus 3. Risk of aspiration is high in elective cardioversion cases with sedation
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ACLS protocol Modifications
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1. Maintain Left Uterine Displacement during chest compressions 2. Hand position should be 1-2 cm higher on the sternum (upward shift of the diaphragm) 3. Premortem C-section should be done (Improves maternal and fetal survival) ----4 minutes within maternal arrest
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Fetal Monitoring with Surgery
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- Baseline and postoperative FHR should be recorded on anesthesia record. - Continuous FHR monitoring possible after 20 weeks gestation (technical difficulties)
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incidence of Pre-term Labor and Delivery
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- Preterm delivery < 37 weeks - 75-80% of all neonatal morality and morbidity
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Pre-term Labor and Delivery due to myometrial contractility secondary to
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Infection Uterine Distention
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Prevention of preterm labor
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Cervical Cerclage Progesterone therapy Tocolytics
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graphs
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slide 32 33
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name Tocolytics
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1. Calcium Channel blocker 2. NSAIDS 3. Beta adrenergic agonists 4. Magnesium Sulfate ----Neuroprotective 5. Oxytocin antagonists 6. Nitroglycerin
