Hall’s OB Anesthesia Question Review

 After low-dose prophylaxis with low-molecular-weight heparin (LMWH) (e.g., enoxaparin 0.5 mg/kg
daily), a time of at least 10 to 12 hours should elapse prior to performing neuraxial techniques to decrease
the likelihood of an epidural hematoma forming (at least 24 hours after high-dose LMWH[e.g., enoxaparin
1 mg/kg twice daily or 1.5 mg/kg daily] used for therapeutic anticoagulation).
 Hypertension during pregnancy is divided into: pre-eclampsia, gestational HTN, chronic HTN, and chronic
HTN w/ superimposed pre-eclampsia.
o Pre-eclmapsia: new onset HTN associated w/ thrombocypotenia (<100), impair liver fxn, renal
insufficiency, pulmonary edema, new onset cerebral or visual disturbances.
 Risk factors: hydatidiform mole, multiple gestations, obesity, polyhydramnios, diabetes.
o Gestational HTN is new onset of HTN during pregnancy, usually after 20 wks gestation.
 Magnesium is often used for seizure prevention in pre-eclampsia:
o 4-8 is therapeutic level
o >10 loss of DTRs
o >15 respiratory paralysis
o >25 cardiac arrest
 Magnesium works by
o Decreasing release of ACh at myoneural junction
o Decreases sensitivity of motor endplate to ACh.
o Can potentiate NDMBs, sux is less clear.
o Ephedrine preferred over phenylephrine w/ Mg because it antagonizes alpha agonists
o Antidote for Mg is Ca++
 Uterine tonics agents include: oxytocin, ergot alkaloids (ergonovine, methylergonovine), and
prostaglandins (PGE2, PGF2a)
o Oxytocin: vasodilation, hypotension when bloused, edema, water retention, hyponatremia when
on long drips.
o Ergot alkaloids: nausea/vomiting, vasoconstriction, contraindicated in HTN / preeclampsia.
o Prostaglandins: PGF2a: bronchospasm. PGE is safe from bronchospasm.
 P50 of newborns is 18mmHg vs adult value is 27mmHg.
o Higher affinity for oxygen, left shift of curve.
 The greatest increase in cardiac output happens immediately after delivery, mostly 2/2 to autotransfusion &
increased venous return with uterine involution. Takes about 2 weeks for CO to return to pre-pregnant
levels.
 Uterine blood flow increases from 50-100ml/min before pregnancy to 700-900 ml/min at term.
 Neuraxial anesthesia is safe in patients with HIV, vertical transmission to baby in untreated moms happens
about 15-40% of the time. With treatment, chances of transmission decreases to 1-2%.
 Patients taking protease inhibitors as part of their HIV regimen inhibits CYP450, leading to prolonged
benzos & narcotic effects.
 Amniotic fluid embolism (AFE) happens when amniotic fluid enters maternal systemic circulation, about
10% of maternal death is d/t AFE.
o Membrane rupture, abnormal open sinusoids, laceration of endocervial veins is how it happens.
o Classic triad: acute hypoxemia, hemodynamic collapse, coagulopathy without an obvious
cause.
o Initially pulm vasospasm w/ significant pulm HTN & right heart failure, followed by left heart
failure and pulm edema
o DIC happens about 2/3 of the time, seizures about 50% of the time.
o Bronchospasm and chest pain are rare.
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