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Barry OB

QuestionAnswer
Name the 4 stages between oocyte and implantation Zygote, 4 cell stage(2d), Morula(3d),early blastocyst(4d), implantation(6d)
Embryonic stage 3rd week
fetal stage 9th week
1951, Lady Euphame Macalyane Burned at the stake on castle hill in Edinburgh, Scotland seeking relief from the pains of child birth
Dr. grupert Lyons, France April, 19, 1836 ides of magnetizing a woman during child birth, to give brth while asleep.
John Young Simpson First OB anesthetic..Ether 19 jan 1847
Charles D Meigs Wrote a Book on OB
James Young Simpson Simpson's forceps and book on witch craft
John Snow First physician anesthetist, chloroform, queen victoria
Nathan Keep 1st OB anesthetic in US Ether 1847
Crawford Long Ether 1842-wife's delivery
Twighlight sleep 1900-1940's scopolamine-morphine
Duke Inhalers contain Cyprane, Penthrane, N2O & O2
Dr. Oskar Kreis SAB/OB 1900
1st C/S with SAB 1902
Einhorn 1905 Procaine
1st Pudendal Block 1908
1st Paracervical block 1926
Koller Eye Block 1884
Sinal Anes OB 1928
Cleland 1928 described pain pathways of uterine contraction
First reported labor epidural 1931
Lidocaine (year) 1943
% increase in body weight during pregnancy 17% or 12kg
Uterus ?kgAmniotic fluid ?kgFetus/Placenta ?kgBlood volume ?kgInterstitial fluid? kgNew fat and protein? kg Uterus 1kgAmniotic fluid 1 kg Fetus4 kg Placenta 4 kg Blood volume 2 kg Interstitial fluid 2 kgNew fat and protein 4kg
Pulmonary Anatomic changes Diaphragm elevation, reduced FRC,capillary engorge. of airways, progesterone induced tracheal and bronchial dilation, cheest expands A/P and transverse diameters
Pulmonary Physiologic changes Decreases-airway resis, TPR,TC,ERV, RV, FRC Increases-MV,AV,TV,RR,ILC,O2 consumption No change VC, CC
In pregnancy base line arterial PO2 increase/decrease by ?mmHg?Arterial PH?Arterial PCO2? APO2 ^10mmHg. APH no change. APCO2 decrease by 10mmHg ABG:chronic hypervent/resp alk
Closing volume lung volume during expiration at which airways begin to close in dependant zones of the lungs
In supine position what happens to a preg. womans closing volume closing capacity will exceed FRC(dec. 20% supine), which means the mother is at risk for hypoxemia.terminal alveoli perfused but not ventilated(VQ mismatch)
Progesterone's effect on the respiratory system sensitizes resp center to CO2, Resp stimulant, reduces airway resistance due to relaxant effect on bronchial smooth muscle
Ventilatory changes during pregnancy MV rises 19-50% by term RR ^9%TV ^28%O2 consumption ^40-60%
The oxy hb curve shifts R/L during a normal pregnancy Right, facilitates O2 unloading to fetus
Additional edema around the airways during pregnancy causes A smaller more fragile airway, smaller ETT careful suctioning
In Preeclampsia we can expect the airway more edematous and edema of the vocal cords
Hypoxia and Hypercarbia are more pronounced ^O2 demand b/c? decreased FRC, so decreased O2 storage,& decrease CO when supine
MAC inc or dec? decreased 25-40%
hyperventilation w/ pain during labor inc/dec uterine BF Uterine BF decreases 25% w/ hypocarbia
Pain relief during labor does what to oxygenation and ventilation? normalizes oxygenation and decreases MV and O2 consumption
RR during pregnancy c/t labor preg.-15 Labor-22-70
TV ml preg vs. labor preg-480-680 Labor-650-2000
MV L/M preg vs. labor preg.-7.5-10.5 labor-9-30
PaCO2 preg vs. Labor preg- 31mmHg Labor-15-20
PaO2 preg vs. Labor preg-105mmHg Labor-100-108
compare preg. abg to non preg preg. 7.44,30,107,20 non.7.44,40,100,24
Significance to the anesthetist smaller ETT, induction rate increased(MAC, FRC,&RR)decreased O2 reserve
Maternal hyperventilation Fetal effects CONSTRICTION UMBILICAL & UTERINE ARTERIES. FETAL ACIDOSIS HYPOCAPNIA MATERNAL HEMOGLOBIN DISSOCIATION CURVE TO THE LEFT (metabolic alkalosis)
oxy hgb dis curve of the fetus is to the L or R of moms? left
CV system BV, CO,SVR changes in preg increased BV Increased CO(40-50%) due to ^ SV(30%) in 1st half of preg and ^SV and HR(15-20%) in 2nd half..SVR decreased
Why is the SVR decreased? ^prostacyclin(vasodilator)progesteronelow resistance placental circulationblood viscosity
Explain physiological anemia of pregnancy BV increases 35-50% plasma volume increases 45% and RBC mass only 20%, viscosity is reduced
T/F RBC and plasma volume continue to increase late into third trimester True
There is no change in CVP T/F True
in a normal pregnancy Blood pressure is increased 10-20% T/F false DBP dec.10-20mmHg, SBP dec. 0-15mmHg,MAP dec.15mmHg
Average EBL at C/S 500-1000
EDG changes during pregnancy Left axis deviation, minor ST, T and Q wave changes and minor arryhthmias (reversible)
most common dysrhythmias of pregnancy premature ectopic atrial and ventricular depolarizations and sinus tachy
mechanisms for ECG changes in pregnancy changes in cardiac ion channel conduction,increase in heart size,changes in autonomic tone,hormonal fluxes
What happens to SV, HR, CO when transitioning from supine in the first stage of labor to lithotomy in the second stage during contractions SV decreases dramatically, CO decreases and HR increases
2 components of aortocaval compression IVC compression and aortoilliac obstruction
IVC compression after 24 weeks gest. alternative circulation azygous vein/paravertebral system**compensatory decrease in sympathetic tone and HR
aortoilliac compression **arterial side compressionNO maternal symptomsplacental BF decreasesFemoral flow vs. Brachial flow-BP normal in arm, low in femoral, causing early or late decells in baby
Changes in blood constituents plasma protein decreases so colloid osm. pressure decreases.leukocyte count increases 12k-20k. All factors increase xcept XI and XIII. enhanced fibrinolysis
Effects of Blood constituent changes pulm edema, drug sesitivity, high risk of DVT and PE
mendelsons recommendations withhold all food during laborgreater use of regionalsantacidsempty stomach prior to GAcompetant administration of GA
Clinical implications for risk of aspiration treat all preg pts as full stomach from 8 weeks gest - 6 weeks post partum.*gastric contents more acidic (ph<2.5) and >25ml, more likely aspirated
Roberts and Shirley recommendations no particulate antacids use Bicitradefined risk as >25ml gastric volume and ph<2.5
risk factors for aspiration in pregnancy ^gastric acid production and pepsin secretion. dec. gastric emptying(w/opioids)incompetence of lower esoph sphincter tone. anatomic displacement
opioid related aspiration risks Diminished gastric emptyingDiminished LES toneDiminished protective airway reflexesDiminished response to hypoxemia/hypercarbia
Agents for aspiration prophylaxis Ranitidine (Zantac)Metoclopromide (Reglan)Oral sodium citrate, 0.3M Bicitra
Airway Management in the Pregnant Patient RSI with Cricoid PressureAnatomical positioningEndotracheal intubations beyond 8-12 weeks and up to 6 weeks post partumNO nasal intubationsGastric suctioning prior to emergenceAwake extubationsDecrease size of endotracheal tubes
Renal system changes URETERS DILATE WK 12 - (a state of hydronephrosis may occur in 80% of women by mid-pregnancy)RBF & GFR INCREASE 50% (^renal blood flow)^Total protein & urinary albumin excretion ^ excretion of glucose^ bicarbonate excretion
Renal implications ^UTI, glycosuria, aldosterone ^total body water and Na levels,normal lab studies may indicate renal problems(bun/Cr should be lower)
Significance to the Anesthetists (renal) preeclampsia has proteinuria caused by glomerular damage.Oliguria is a consequence of arteriolar damageand spasm which may lead to acute tubular necrosis.
HEPATIC SYSTEM MINOR INCREASES IN SGOT & LDHBLOOD FLOW UNCHANGEDPLASMA CHOLINESTERASE LEVELS INCREASESCOLLOID ONCOTIC PRESSURES decrease COAGULATION FACTORS INCREASE
CLINICAL IMPLICATIONS HEPATIC SYSTEM HYPERCOAGULABILITY HEPATIC PROTEIN INCREASE BUT DILUTED IN INCREASE PLASMA VPROL0NGATION OF Sux AND chloroprocaineprogest dec.biliary motility ^chol.^risk GB disease
CENTRAL NERVOUS SYSTEM NEURAL SENSITIVITY TO LOCAL ANESTHETICS INCREASES, RELATED TO PROGESTERONEENGORGEMENT OF EPIDURAL VEINS, DECREASES EPIDURAL & SUBARACHNOID SPACESMAC DECREASES 25 - 40%
Anesthetic Requirements implications of CNS in Pregnancy Swelling of epidural veins decreases volume of CSF in vertebral column. Labor induced increases in CSF pressures. Increased neurosensitivity to local anesthetics.
Dose of LA and Mac changes LA dose dec. 20-30%MAC decreased 25-40%
CLINICAL IMPLICATIONS of reduced LA and MAC Progesterone and Beta-endorphins systems contribute to decreased anesthetic requirementsincreased risk for LA toxicity
increase in uterine BF non preggers 50-100cc 70Gpreggers 700cc 1100G
UBF is directly proportional to change in BP
UBF is inversely proportionate to uterine vasc. resistance
UBF= UAP-UVP/UVR
Placenta increta inside myometrium
Placenta excreta outside uterus
Uterine vasculture is not autoregulated T/F true
If they can't stop bleeding after birth what artery do they tie off? hypogastric
common iliac inc. or dec. BF to the uterus increases
External iliac inc. or dec. BF to the uterus decreases
describe "steal phenomenon" blood flow in the pelvis is preferentially redistributed toward the uterus
When is the best time to administer an opioid to mom and avoid baby getting doped up during a contraction
Factors Causing Decreased Uterine Blood Flow Uterine ContractionsHypertonusHypotensionHypertensionVasoconstriction, endogenousVasoconstriction, exogenousmost sympathomimetics(alpha-adrenergic) Exception ephedrine(beta)
Vasopressor of choice Ephedrine b/c it won't cause vaso constriction of uterine arteriesdue to release of NO
ephedrine stimulates what receptors to get what outcome Beta adrenergic for inc. CO as opposed to vasoconstriction although it has been found to decrease umbilical cord PH 7.3-7.4
Why would you choose not to use phenylephrine? causes uterine artery constriction & bradycardia, but it does leave umbilical cord PH higher than ephedrine
Regional anes effect on uterine BF causes a sympathectomy which dec. UBF
At what dose might propofol start to have an effect on UBF 2mg/kg
What effect does Thiopental have on UBF none upto 5mg/kg
What effect does 1.5-2 mg/kg of Ketamine have on UBF? decreased UBF, use 1mg/kg
inhalation agents effect on UBF none if kept at 1 MAC or lower..>than 1 MAC dec. UBF
hyperventilation effect on uterine BF decreases
Function of placenta Produces hormones to sustain pregnancyProtects fetus from the maternal immune systemAllows for active & passive transport of nutrients & metabolites
Size of placenta 500g disk shaped 20cm 3cm thick
drug placental transfer..what will cross higher concentration, low ionization, higher lipid solubility, and lower MW.low protein binding. If it passes BBB it will pass placenta.
Facilitated transport carrier mediated lipid soluble molecules-more stereo specific temp regulated
Active transport movement of any substance accross a call membrane-a.a. proteins-sim to translocation-Na/K atpase pump
pinocytosis transport immunoglobulins, larger macromolecules, inc. energy to get accross
lidocaine protein binding? low so it passes through placenta easily..can cause ion trapping if distressed fetus
Marcaine protein binding? High..doesn't pass, but takes too long.
LA of choice for fetal distress chloroprocaine
ion trapping if the fetus is in metabolic acid. when the LA or opiod enters fetal circ it quickly becomes ionized in low PH and cannot cross back out. builds up->toxic
What induction agent should you use to treat a seizure in mom Thiopental
Why wouldn't you use Benzos decrease temp regulation and hypotonia of baby
NDMR cross placenta? No highly ionized quartenary ammonium salts
anticholinergic of choice Robinol does not cross..Atropine and Scop do.
opioids cross placenta? Yes
Anticholinesterase cross? limited..ionized quats
antihypertensives/vasopressors cross--no ACE inhibitors during pregnancy
Mag sulfate effect on UBF increase
Regional anesthesia effect on UBF reduced by causing hypotension and increased by relieving pain,dec symp activity and dec.hypervent.
Meperidine timing for adm during labor If delivery will be within 1 hour or 4 hours after administration..also can accumulate and cause seizures
Created by: Jennifer Birne Jennifer Birne on 2010-06-25



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