6-30-10 OB Midterm Summary All Slides - Barry
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| How old does pt need to be to consent to lubal | 21
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| Can consent for tubal be given during labor | No
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| Can consent for tubal be given while under going abortion | No
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| Can consent for tubal be given while on drugs | No
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| Can consent for tubal be given and surgery performed within 30 days | No, 30 day waiting period
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| Can consent for tubal be given and surgery performed within 181 days | No, consent only good for 180 days
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| What does Suxx last longer post-partum | Lower cholinesterase levels
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| What med used for aspiration prevention causes prolonged Suxx time | Reglan (metoclopramide)
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| Are most drugs given secreted in breast milk | Yes
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| Is ESWL safe during pregnancy | No, contraindicated
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| Does anesthesia cause fetal malformations | No
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| Does anesthesia cause IUGR | Possibly
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| What respiratory items decrease during pregnancy | PaCO2(10 mmHg), Serum HCO3 (by 4 mEq/L), FRC (20%), ERV (by 20%), RV (by 20%)
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| MAC decreases by how much during pregnancy | 40%
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| What decreases cardiovascular wise with pregnancy | SVR, SBP, DBP
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| What decreases with regards to renal with pregnancy | Serum creatinine and BUN
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| What increases hematologically during pregnancy | Coagulation factors (II, V, VII, VIII, IX, X, XII), Plasma 50%, RBC 35%
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| What decreases hematologically with pregnancy | Hg, platlets, lymphocytes
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| Most all anesthetics make their way to the fetus except | Paralytic agents- they are quaternart ammonium salts
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| If a teratogen is given to effect organogenisis when would it be given | between 15 days to 56 days gestation
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| A classification of "A" of teratogen risk means | Controlled studies should no risk to humans
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| A classification of "C" of teratogen risk means | Risk cannot be ruled out
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| A classification of "D" of teratogen risk means | Positive human evidence of fetal risk
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| A classification of "X" of teratogen risk means | It is contraindicated
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| Most anesthetic drug are classified as "B" or "C" teratogen risk except for | Benzodiazepines - "D"
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| Thalidomide babies have | malformed limbs due to ingestion of sedative (thalidomide) during early gestation
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| Cerebral Palsy is caused by | Hypoxia or hypotension in late gestation
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| What is the highest incidence (65-70%) of cogenital abnormalities of fetus | Its unknown (next highest-20% is genetic transmission)
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| What are some documented teratogens | ACE inhibitors, alcohol, cocaine, coumadin, depakote
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| The most serious fetal risk during pregnant surgery | Asphyxia (insufficient O2)
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| When does maternal positioning start to matter | 20 weeks when uterous leaves the pelvis at umbilicus level
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| When does fetal monitoring become practical | After 16 weeks
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| What is the best measurement of your skill when delivering anesthetic during pregnancy | Fetal monitor (fetal heart rate)
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| Has any study shown one anesthetic to be more prone top cause preterm labor | No
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| Which trimester has lowest risk for surgery producing preterm labor | 2nd trimester
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| Name 4 drug classes that are used to stop labor | Beta adrenergic agonist, Mg sulfate, Prostaglandin synthetase inhibitors, and Ca channel blockers
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| What fetal effects do Beta blockers cause | Hyperglycemia, tachycardia, those related to mom's hypotention
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| What effects do MgS04 have on fetus | hypotonia, drowsiness, decreased gastric motility, hypocalcemia
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| What effects do prostaglandin synthetase inhibitors have on fetus | Premature closure of ductus arteriosus, and pulmonary HTN
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| What effects do CA blockers have on fetus | Methemoblobinemia
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| Pneumoperitoneum pressures for pregnant laparoscopy should be | between 12-15
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| What is EXIT procedure | Fetus is removed from uterus while cord stays intact until airway (ett, trach) can be established, the cord cut (done for fetal high airway obstruction, pleural effusion)
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| What is the dose of fetal Fentanyl IM | 5-20 mcg/kg
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| What is the dose of fetal Vecuronium | 0.2 mg/kg
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| What is the dose of fetal epinephrine | 1 mcg/kg
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| What is the dose of fetal atropine | 0.02 mg/kg
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| Recurrent second trimester pregnancy losses could be the result of | Incompetent Cervix
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| What is a treatment for incompetent cervix | Cervical cerclage (increases fetal survival rate from 20% to 89%
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| Name 3 types of Cervical cerclage | Shirodkar, McDonald (both transvaginally), and Transabdominal
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| When are cervical cerclages performed | between 12 and 26 weeks
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| Contraindications to cervical cerclage (7 of them) | Active bleeding, Active labor, ruptured membranes, dilation > 4 cm, infection, fetal abnormalities, and abruptio placenta
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| What level do you need for cervical cerclage | T8-T10
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| The leading cause of maternal death | Trauma
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| What is a main cause of Abruptio Placenta | Trauma
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| Sodium nitroprusside may cause fetal ? | cyanide toxicity
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| MAP with neurosurgery should be | >70
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| The portion of the fetus closest to the cervical Os is the definition of | Presentation
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| Name 3 cephalic presentations | Vertex (back of head), Brow (head position 1/2 way between vertex and face presentation), and Face (extended sniffing)
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| Is a breech position transverse or longitudinal | Longitudinal (in reference to moms spine)
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| Name 3 Breech positions | Frank (looking at his frankfurter- legs up), Complete (Indian style), Incomplete (one leg more extended either up or down)
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| Name a tranverse presentations | Shoulder
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| Transverse and longitudinal are types of | Lie
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| What is the most common type of breech position | Frank
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| What are main causes for abnormal presentations | Aberrant uterine shape, decreased uterine constraint (IUGR, premature), increase uterine constaint, and previous Hx of same
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| Umbilical cord prolapse is most common with which breech position | Incomplete
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| ECV stands for | External Cephalic Version (trying to turn the fetus by pushing on the outside of moms abdomen
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| Fetal head entrapment greatest in what gestational age | >32 weeks
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| Treatmens for fetal head entrapment (4 of them) | C section, Duhrssen incision, GETA (2-3 MAC), Nitroglycerin (IV 50-500 mcg or 2 sublingual sprays)
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| Twins from one ovum are called | Monozygotic Twins
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| Twins from two separate ova are called | Dizygotic twins (more common in african american)
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| Twin gestation increases blood volume over regular pregnancy by | 500 ml
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| Twin to twin tranfusion occurs in which situation - monozygotic or dizygotic | Both if they have the same (or fused) placenta
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| The most common medical disorder of pregnancy | Hypertension
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| What is the definition of perinatal | The period starts at 28 weeks gestation and goes through 28 days after delivery
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| What percent of pregnancy have HTN | 6%-8%
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| What is the percent of preclampsia all of pregnancies in U.S. | 4%
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| What is the percent of Eclampsia in pregnancy | up to 0.05% (0.5% of preeclampsia population)
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| Coma and convulsive seizures between the 20th week gestation and the end of the first week postpartum is the definition of | Eclampsia
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| The most common cause of HTN during pregnancy | Gestational HTN
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| What is the start and stop time of the HTN in gestational HTN | Starts 20 th week gestation and end 12 weeks postpartum (most start at 37 weeks gestation)
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| Is there proteinurea in Gestational HTN | NO (that would be preeclampsia)
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| What would HTN be called if it started prior to 20 weeks gestation and continued after 12 weeks postpartum | Chronic HTN
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| Overall the most commonly essential HTN | Chronic HTN
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| What can Chronic HTN develop into | Superimposed preeclampsia
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| Onset of HTN and proteinurea after 20 weeks gestation is called | Preeclampsia
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| 75% of preeeclampsia are "Mild" defined as (2 things) | BP >/= 140/90 mmHg after 20 wks and Proteinurea 300mg/24hr (or +1 on dipstick)
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| Severe Preeclampsia is defined as (10 things) | BP >/= 160/110 mmHg (on 2 occasions at least 6 hours apart), proteinurea >/= 5 g/24hr, Oliguria (<500ml/24hr), Elevated Serum Creatinine, Cerebral or visual disturbances (Headache), Pulmonary edema with resp distress, Liver dx, RUQ pain, IUGR, and Thrombo
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| HELLP stands for | Hemolysis, Elevated Liver Enzymes, and Lowered platlets
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| The "E" ion HELLP is specific for | elevated hepatic transaminases
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| Why are platlets low in HELLP syndrome | they are decreased secondary to an increase rate of consumption
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| How is hemolysis diagnosed in HELLP | usually by the presents of schistocytes in a peripheral blood smear (microangiopathic - small vessels tear cells apart)
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| What physiologically happens in eclampsia | Diffuse vasospasm of cerebral vessles leads to cerebral ischemia
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| Risk factors for preeclampsia | Nulliparity, Hx of, > 35yr old, Non-Hispanic African American, Obesity, HTN, DM, Sickle cell Dz, Smoking, Multiple gestation, Hydatidform mole, Abnormal Placenta, and Materal Syndrome
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| Most current released theory of preeclampsia | Antiangiogenic Protiens
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| The vasospasm that occur in preeclampsia are caused by an increase in circulating levels of | renin, aldosterone, angiotensin, and catecholamines
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| What causes the edema in preeeclampsia | Aldosterone by retaining Na and H2O
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| What happens to the plasma level in preeclampsia | decreases by 30-40%
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| What increases (4 things) that imply hypercoagulation in preeclampsia | Common pathway activity, Fibrin degradation products, Factor VIII and its activity, Platlet aggregability
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| What decreases (4 things) to imply hypercoagulation in preeclampsia | Fibrinogen, Antithrombin III, Platlets, and Sensitivity to prostacyclin
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| What happens with Renal in preeclampsia | Decrease in renal blood flow (20%), decrease GFR (30%), decrease uric acid clearance (elevated uric acid levels), proteinurea, and glomerular endotheliosis
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| 60 % of pts with acute fatty liver disease have | Preeclampsia/HELLP, hemorrhage, even Liver rupture
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| What happen with the brain in preeclampsia (4 things) | Headache, eclampsia, visual disturbances (including cortical blindness), and seizures
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| What happens hematologically with preeclampsia | Hemolysis, thrombocytopenia, platlet disfunction, and increased platlet consumption
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| What effects on the respiratory system does preeclampsia have (4 things) | Edema (laryngeal, upper airway, and pulmonary), pulmonary capilary leak, increased sucretions and congestion
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| Why does pulmonary edema take place in preeclampsia | Low colloid oncotic pressure, increased pulmonary capillary permeability, ventricular disfunction, and increased intravascular hydrostatic pressure
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| Does respiratory issues with preeclampsia happen more frequent antepartum or postpartum | Postpartum 70% (Antepardum 30%)
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| What placenta effects does preeclampsia have (5 things) | Intervillous blood flow decreases 2-3 fold, Hypoperfusion (premature labor), Chronic fetal hypoxemia, IUGR, Placenta abruption is more common
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| Management for preeclampsia includes (6 things) | Antihypertensive Tx, Anticonvulsant Tx, Urteroplacental perfusion management, Analgesia for L&D, L&D management, and Surveillance of fetus and materal
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| What is used for longterm management of HTN in preeclampsia | Aldomet and Labetalol
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| Name tx for htn in preeclampsia (5 of them) | Hydralazine, Labetolol, Calcium channel blockers, Nitroglycerin, and Sodium Nitroprusside
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| What is the first line anticonvulsant treatment for preeclampsia | Mag Sulfate
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| How does Mag sulfate prevent seizures | Cerebral and peripheral vasodilator, NMDA antagonist, and NMJ effect
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| What is the MgSO4 dose | 4-6 g over 20 min, then 1-2 gram/hr
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| What is the theraputic level of MgSO4 | 6-8mg/dl
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| MgSO4 causes ECG changes at what plasma level | 5 meq/L
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| What plasma level does MgSO4 cause resp depression at | 10 meq/L
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| What plasma level does MgSO4 cause resp arrest at | 15 meq/L
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| What plasma level does MgSO4 cause cardiac arrest at | 25 meq/L
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| What are the side effects of mag sulfate | Thing get weak and floppy (NMB last longer also)
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| What is the etiology for neuromuscular effects from Mag sulfate | Decreases acetylcholine release from nerve terminal, decreases sensitivity of acetylcholine at endplate, and depresses the excitability of skeletal muscle membrane
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| Five things preeclampsia can lead to | CVA, Pulmonary edema, Renal failure, Placenta Abruption, and HELLP (Hemolysis, Elevated Liver enzymes and Low Platlets)
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| What is the level of bilirubin in HELLP | > 1.2 mg/dl
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| What is the level of Lactic dehydrogenase in HELLP | > 600 IU/L
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| What is the level of SGOT in HELLP | >/= 70 IU/L
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| What is the platelet level associated with HELLP | < 100,00/mm3
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| HELLP can lead to (9 things) | Pulmonary edema, ARDS, Placenta abruption, DIC, Ruptured liver (hematoma), Acute renal failure, severe Ascites, Cerebral edema, and materal death
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| A women who is not now or never has been pregnant | Nulligravida
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| Time frame after delivery | Postpartum
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| A women who is or has been pregnantirrespective of the pregnancy outcome | Gravida
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| Time frame before delivery of fetus | Antepartum
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| Refers to a women's previous pregnancies of at least 20 weeks gestation | Parity
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| A term delivery happen when | Between 37 and 41 weeks
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| A women who is pregnant for the first time beyond the stage of abortion | Primigravida
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| When is the third trimester | begins at 27 weeks and ends at delivery
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| Delivery when infant delivers after 42 weeks gestation | Postterm
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| A women who has completed two or more pregnancies beyond the stage of abortion | Multigravida
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| Delivery that occurs prior to 37 weeks gestation | Preterm
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| A women who has never completed a pregnancy beyong an abortion | Nullpara
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| The period from 13 weeks to 26 weeks from the last menstrual period | Second trimester
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| A women that has delivered a viable fetus past the stage of abortion | Primipara
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| The period the begins at conception and ends at 13 weeks from last mentrual period | First trimester
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| A women in labor | Parturient
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| A women who had just given birth | Puerpera
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| Most HELLP pts have what type of delivery | C-section
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| What is an indicator for PA cath placement | Evidence of CHF
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| Benefits of regional anesthetics in preeclamptic patients (9 of them) | Pain relief and relaxation, decreased catecholamines, increased uteroplacenta blood flow, no parental narcotic systemic effects, control of BP, permits low outlet forcepts, njo pulm. edema, can use for c-section, and decr. aspiration
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| Eclampsia is highest risk at age | < 20yrs
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| What is the clinical presentation of eclampsia | Headache, blurred vision, photophobia, RUQ or epigastric pain, hyperreflex, and altered mental status
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| Facial twitching, tonic phase (persisting about 15-20 seconds) progresses to what in eclampsia | Generalized clonic phase with 1 min apnea then postictal and coma
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| First line drug with eclampsia | Mag Sulfate
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| 2nd and third line drugs for eclampsia | Antihypertension agents then thiopental, propofol, versed
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| Amniotic fluid emboli triad | Dyspnea, Cyanosis, Carviovascular Collapse
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| Amniotic fluid embolism - % fatal | 20-80% fatal
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| Amniotic fluid embolism account for what percent of maternal deaths | 12% of materal deaths (5 in 100,000 births)
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| Name all the predisposing factors for Amniotic fluid embolism | Just one - The fact of being pregnant
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| Three things that need to be present for Amniotic fluid embolism | Amniotomy, laceration of endocervical or uterine vessel, and Pressure gradient to force fluid into materal circulation
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| What causes Amniotic fluid embolism to be deadly | The Biochemical mediators it contains (prostaglandins, leukotrienes), they cause vasoconstrictions, vasodilation, and inotropic effects
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| How do you diagnose AFE | By exclusion
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| Amniotic fluid embolism cause what to resp system | Hypoxemia - pulmonary vasospasm
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| Amniotic fluid embolism causes what to cardiovascular system | Hypotension, tachycardia leading to cardiac arrest
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| If one survives Amniotic fluid embolism, what happens hemodynamically | Coagulopathy in 66% of pt (DIC 80% of the 66%)
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| The cascade of Amniotic fluid embolism | Resp distress, cerebral hypoperfusion, Hemodynamic collapse, Hemorrage, then multi-organ failure and infection
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| Top 3 (seen more than 90 % of the time) S/S of Amniotic fluid embolism | Hypotension (100%), Fetal distress (100%), and Pulmonary edema (93%)
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| Main priority for Amniotic fluid embolism recovery | Get the BP up - pressers, fluids
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| Venous Air Embolism (VAE) occurred in 97% of pts receiving | General anesthesia
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| Is VAE rare | No, VAE is a common occurance
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| The lethal amount of air in VAE | > 3 ml/kg
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| 50% of VAE pts had these on the monitor | ECG changes - ST depression
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| First action with VAE | Flood the field
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| What often is the begining cause of Pulmonary thromboembolism (PTE) | DVT
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| When is PTE most likely to occur | Postpartum
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| Up to what percent of untreated pregnant DVT result in PTE | 15-24 % end up with PTE
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| The etiology of PTE (3 things) | Venous stasis, increased hypercoagulable r/t pregnancy), and vascular injury (r/t vaginal or c-section trauma)
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| Most pronounced finding in PTE (85% of the time) | Tachypnea
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| When is it ok to start DVT therapy with Warfarin | Postpartum (it crosses the placent easily - Heparin can be given antepartum)
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| How long after Low molecular weight heparin (LMWH) can a neuraxial be attempted | 12-hrs (same time frame when removing epidural catheter
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