Obstetric Anesthesia Rotation Pretest

Dear resident, please complete the following pretest. This will help pinpoint weaknesses in your
obstetric anesthesia knowledge base in order to focus on them during the rotation.

1- What are cardiovascular changes that occur at term in pregnancy?

There is an increase in left ventricular end-diastolic volume and no change in left
ventricular end-systolic volume resulting in an increased ejection fraction. Cardiac
contractility is increased, systemic vascular resistance decreases, and heart rate increases.
Mean blood pressure (BP) gradually falls during pregnancy, with the largest decrease in
BP typically occurring at 16 to 20 weeks. BP then begins to rise during the mid-third
trimester to levels approaching prepregnancy BP values.
Cardiac output gradually increases during the first 2 trimesters with the largest increase
occurring by 16 weeks of gestation. The rise in cardiac output typically plateaus after 20
weeks of gestation and remains elevated until term.
Total peripheral resistance decreases very early during pregnancy and continues to
decrease throughout the second and third trimester.

2- What are the changes in the anatomy or physiology of the stomach that are
associated with pregnancy?
The stomach is displaced upward and toward the left side of the diaphragm and its axis is
rotated 45 degrees to the right. This displaces the intraabdominal portion of the
esophagus into the thorax, thus reducing lower esophageal sphincter tone. In addition,
progestins also contribute to a relaxation of the lower esophageal sphincter tone. There is
increased acid secretion and increased gastric emptying time.

3- A patient presents for repeat cesarean section. Shortly after the administration of
spinal anesthesia, the patient begins to complain of shortness of breath. Her blood
pressure is 80/40 and her heart rate is 48 bpm. The patient tells you she is
nauseated, short of breath, and her hands are tingling. Within a few minutes the
patient becomes unresponsive, profoundly hypotensive, and apneic. What should be
the appropriate management?

The patient has progressed to a total spinal anesthetic. Immediate airway and circulatory
support are vital. Securing the airway via endotracheal tube with 100% oxygen, left
uterine displacement, and prompt administration of vasopressors (epinephrine) are all
critical to the care of this patient.
4- What is this type of decelaration?

This is early deceleration. It start when the uterine contraction begins and recover when
uterine contraction stops. This is due to increased fetal intracranial pressure causing
increased vagal tone. It is considered to be physiological and not pathological.

Late decelerations begin at the peak of the uterine contraction and recover after the
contraction ends. It indicates there is insufficient blood flow to the uterus and placenta.
Reduced uteroplacental blood flow can occur due to maternal hypotension, pre-
eclampsia, uterine hyperstimulation.
 Variable decelerations are observed as a rapid fall in baseline fetal heart rate with a
variable recovery phase. They are variable in their duration and may not have any
relationship to uterine contractions. Variable decelerations are usually caused by
umbilical cord compression.

5- What are the criteria for diagnosis of preeclampsia?

6- Describe Plasma cholinesterase levels during pregnancy

Plasma cholinesterase levels are typically decreased by 25% during pregnancy. The
decreased concentrations do not result in clinically significant effects on ester-type local
anesthetics or succinylcholine in the doses generally used.

7- What are methods to prevent maternal hypotension during cesarean? What about
head down tilt?
Methods to prevent maternal hypotension include fluid administration, lateral
displacement of the uterus, and infusion of a vasopressor. A head-down tilt may result in
more cephalad spread of a hyperbaric local anesthetic solution. This will potentially
increase the level of the block and cause more hypotension.
8- What are the well-known changes that occur in the central nervous system of the
parturient?
Anesthetic requirements are decreased in pregnancy, with 25% less local anesthetic
needed for regional anesthesia. Anatomic changes, such as distended epidural veins or
decreased volume of CSF, increase spread of local anesthetics. However, these changes
are also seen in the first trimester, well before significant mechanical changes have
occurred.
It is postulated that pregnancy-induced hormonal changes in nerve tissue sensitivity are
also responsible for the altered sensitivity to local anesthetics. Increased progesterone
concentrations may be responsible for the 25% to 40% reduction in MAC to general
anesthetics. Endorphin concentrations rise during pregnancy thus contributing to an
elevated pain threshold.

9- If twenty minutes after an epidural, you are called to the labor room because the
patient is complaining of shortness of breath and is still in pain. A quick sensory
exam reveals a much higher level on the right side of the patient with a patchy
sensory block. There is no fetal distress and the patient is oxygenating well. What
should be your next step in the management of this patient?

This most likely represents a subdural placement of an epidural catheter. The block
does not follow the typical pattern and may be characterized as patchy or extensive and is
often higher than expected. It can be confused with subarachnoid injection of local
anesthetic. Treatment consists of recognizing the subdural placement, supportive
measures, and replacement of the catheter

10- What is the most common cause of severe postpartum hemorrhage?

Uterine atony is the most common cause of severe postpartum hemorrhage accounting
for approximately 80% or more of cases of primary (within the first 24 h of delivery)
postpartum hemorrhage. Despite preventative measures, postpartum hemorrhage occurs
in 4%-6% of pregnancies.

11- If you want to perform an epidural blood patch (EBP) on a patient who had a wet
tap two days prior during the placement of her labor epidural. What should you
explain to her about EBP?
Prophylactic epidural saline bolus has not been shown to be effective in decreasing the
incidence of PDPH. MRI studies obtained after EBP have confirmed a predominantly
cephalad spread of injected blood, therefore the lowermost interspace should be used.
Most anesthesia providers inject 10-20 mL of blood. Success rates of up to 85% have
been cited after performance of a single EBP with a 98% success rate after a second EBP.
Ninety-five percent of postdural puncture headaches last less than one week,
although rarely symptoms may last months or even years.
12- Compare regional anesthesia to general anesthesia for cesarean section, regarding
maternal death
General anesthesia is associated with an increased risk of maternal death. This is partly
due to the physiologic changes associated with pregnancy. The introduction of alternative
airway devices in the recent past as well as the development of the difficult airway
algorithm has contributed to the decreased risk of maternal death with general anesthesia
as compared to regional anesthesia from a 16.7- to a 1.7-fold increased risk.

13- What is the supine hypotensive syndrome?

In the supine position, cardiac output will be decreased because of the weight of the
uterus primarily on the inferior vena cava although compression of the aorta also occurs.
Up to 15% of term parturients will experience bradycardia and a substantial drop in blood
pressure when supine resulting in supine hypotension syndrome. A 10-15 degree left
lateral tilt is recommended in parturients beyond 17 to 20 weeks gestational age.

14- In order for an epidural to relieve the second stage of labor, the epidural must cover
which one of these dermatomes?
The second stage of labor involves the distention of the vaginal vault and perineum.
These impulses arise from the pudendal nerves that are composed of lower sacral fibers
(S2-S4).

15- On the postpartum floor the patient is on Mg infusion. Her blood pressure is 110/60,
heart rate is 70, and she is in severe respiratory distress. What would be the
management of this patient?
The patient is experiencing magnesium toxicity. Initial management should be directed
toward treating the respiratory compromise with either bag-mask ventilation or obtaining
a definitive airway when available. Calcium gluconate should be administered as soon as
possible in this patient with presumed magnesium overdose. The magnesium infusion
should be shut off immediately and a magnesium serum level should be obtained to
confirm the diagnosis.

16- Talk about drug action and placental transfer of drugs in a parturient (muscle
relaxant, opioids, inhalation, N2O, anticholinergic).
Many drugs administered to the parturient cross the placenta and have neonatal effects
ranging from fetal heart rate changes to neonatal depression. Opioids are the most
commonly used agents during labor and may produce neonatal depression depending
upon the total dose and time interval from administration to delivery of the fetus.
 Inhalational agents rapidly cross the placenta and cause uterine relaxation. Muscle
relaxants have minimal transfer. The anticholinergic agents atropine and scopolamine do
readily cross the placenta. In contrast, glycopyrrolate does not.

17- Regarding placental transfer of drugs, which favors increased maternal to fetal
drug transfer?
Factors affecting drug transfer across the placenta include drug size, lipid solubility,
protein binding, pKa, pH, and blood flow. It is the free unbound drug fraction that more
easily crosses the placenta.

18- What is meralgia paresthetica?

Meralgia paresthetica is a neuropathy of the lateral femoral cutaneous nerve and is
probably the most commonly encountered neuropathy related to childbirth. It may
arise during pregnancy or intrapartum. The most likely cause is entrapment of the nerve
as it passes around the anterior superior iliac spine beneath or through the inguinal
ligament. It is manifested as numbness, tingling, burning, or other paresthesia.

19- A 27-year-old primipara at term in labor at 8 cm ruptures her membranes

spontaneously, sits up, and states, "My heart." She then becomes hypotensive and
unresponsive. She begins to have significant vaginal bleeding shortly afterwards.
What is the most likely etiology?
Amniotic fluid embolism occurs when fetal tissue gets into the maternal circulation. It is
reported to occur during tumultuous labor. It is now thought to be secondary to a massive
autoimmune response to the fetal tissue rather that a true embolus to the pulmonary
artery. Patients experience cardiovascular collapse and become coagulopathic. Immediate
delivery of the fetus along with aggressive resuscitation and extracorporeal membrane
oxygenation may be indicated. Despite these efforts, the mortality rate remains high and
intact survival remains low.

20- What is the local anesthetic that attains the lowest fetal concentration relative to
maternal concentration?
2-chloroprocaine is metabolized rapidly by plasma and tissue esterases, therefore it does
not attain a high concentration in the fetus. The other agents also cross the placenta but
are broken down more slowly resulting in higher maternal:fetal ratios.
Local anesthetics are weakly basic drugs that are principally bound to 1-acid
glycoprotein. Placental transfer depends on three factors: (1) pKa, (2) maternal and fetal
pH, and (3) degree of protein binding. Except for chloroprocaine, fetal acidosis produces
higher fetal-to-maternal drug ratios because binding of hydrogen ions to the nonionized
form causes trapping of the local anesthetic in the fetal circulation. Highly protein-
bound agents diffuse poorly across the placenta; thus, greater protein binding of
 bupivacaine and ropivacaine, compared with that of lidocaine, likely accounts for their
lower fetal blood levels. Chloroprocaine has the least placental transfer because it is
rapidly broken down by plasma cholinesterase in the maternal circulation.

21- What is the most common cause of mortality in a patient with severe preeclampsia?

Magnesium sulfate is used in preeclampsia to prevent seizures. Acute treatment of

elevated blood pressure, most commonly with hydralazine or labetalol, is used to prevent
cerebrovascular complications cited as the most common cause of mortality in patients
with severe preeclampsia

22- Which one of the following changes in laboratory values is expected during
pregnancy?
Pregnancy is associated with many laboratory deviations from "normal." Hemoglobin
and hematocrit decrease, platelets remain unchanged or decrease, and most coagulation
factors increase, BUN and creatinine decrease, and both bicarbonate and Pco2 decrease
resulting in little change in pH.

23- Describe Apgar scores

24- What are the respiratory changes during pregnancy at term?

FRC decreases at term. There is an increase in dead space, tidal volume, lung
compliance, and inspiratory reserve volume at term.

25- What are absolute contraindications to major conduction anesthesia in parturients?

Patient refusal, infection at the site of needle insertion, hypovolemic shock, severe
coagulopathy. Preexisting neurologic disease of the spinal cord is a relative
contraindication.