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UBP Question 6

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Question 6



(Short Form)

A 28 year old, 104 kg, G2P1female,with premature rupture of membranes at 33 weeks gestation and preeclampsia, is being induced secondary to maternal fever, suspected chorioamnionitis, and fetal tachycardia. She is requesting an epidural for vaginal delivery. Her history includes multiple sclerosis, migraine headaches, asthma, and aortic stenosis with a mean transvalvular gradient of 50 mmHg. She is receiving albuterol for asthma, digoxin for aortic stenosis, methylprednisolone for multiple sclerosis, antibiotics for suspected chorioamnionitis, and 80 mg of enoxaparin BID for deep vein thrombosis that developed during this pregnancy. BP = 146/88 mmHg; Temp. = 38.8 °C; Platelets = 115,000.

Pre-operative Management


1) What do you think of her aortic transvalvular gradient?

UBP Answer: Complete answer is found in the UBP Practice Set #3

2) Does this patient require bacterial endocarditis prophylaxis?

UBP Answer: Complete answer is found in the UBP Practice Set #3

3) Would you agree to a labor block?

UBP Answer: Complete answer is found in the UBP Practice Set #3

4) Would the drop in SVR often associated with neuraxial anesthetics improve flow through this patient’s stenotic aortic valve?

UBP Answer: Complete answer is found in the UBP Practice Set #3

5) Assuming you were willing to place an epidural for labor, how long would you have to wait following her last dose of enoxaparin?

UBP Answer: Complete answer is found in the UBP Practice Set #3

6) If it had not been enough time yet, could you check an anti-Xa level or administer protamine to reverse the affects of enoxaparin?

UBP Answer: Complete answer is found in the UBP Practice Set #3

7) Would you require any special monitoring at this point?

UBP Answer: Complete answer is found in the UBP Practice Set #3

8) Assume it has been an appropriate amount of time since her last dose of enoxaparin. How would you provide neuraxial anesthesia to control her labor pain?

UBP Answer: Complete answer is found in the UBP Practice Set #3

9) How does aortic stenosis affect the heart?

UBP Answer: Complete answer is found in the UBP Practice Set #3


(Long Form)


A 28 year old, 104 kg, G2P1 female, with premature rupture of membranes at 33 weeks gestation and preeclampsia, is being induced secondary to maternal fever, suspected chorioamnionitis, and fetal tachycardia. She is requesting an epidural for vaginal delivery.


PMH: The patient developed exertional dyspnea 9 months ago secondary to worsening aortic stenosis. She was planning corrective surgery when she discovered she was pregnant. She subsequently refused any procedures, including balloon valvotomy, until after the baby was born.Her medical history also includes asthma, migraine headaches, multiple sclerosis, and deep vein thrombosis that developed during this pregnancy.

PSH: No previous surgery

Medications: Digoxin, albuterol, methylprednisolone, antibiotics, and enoxaparin 80 mg BID

Allergies: NKDA

PE: Vital Signs: HR 90; BP = 146/88 mmHg; R = 10; T = 38.8 °C
Airway: Mallampati III
Heart: RRR; 3/6 systolic ejection murmur radiating to the apex
Lungs: CTA Bilaterally
Extremities: Edema noted in the lower extremities

ECG: NSR, Left ventricular hypertrophy

Echo: Severe aortic stenosis; mean transvalvular gradient of 50 mmHg, EF = 50%

Lab: Hgb = 12.6 g/dL; Plt = 115,000; Urinary Protein = 400 mg collected over 24 hours


Intra-operative Management


1) After multiple attempts at placement, you enter the intrathecal space with the epidural needle. Would you place an intrathecal catheter for neuraxial anesthesia?

UBP Answer: Complete answer is found in the UBP Practice Set #3

2) What are the signs and symptoms of post-dural puncture headache?

UBP Answer: Complete answer is found in the UBP Practice Set #3

3) You place an epidural catheter which is working well for labor, but the baby’s heart tones are non-reassuring and the obstetrician wants to perform a cesarean section. Would you provide any preoperative medications?

UBP Answer: Complete answer is found in the UBP Practice Set #3

4) Is steroid supplementation necessary?

UBP Answer: Complete answer is found in the UBP Practice Set #3

5) The baby’s heart tones go down into the 50’s for 4 minutes and the obstetrician makes the cesarean section emergent. Would you use her neuraxial catheter for the cesarean section?

UBP Answer: Complete answer is found in the UBP Practice Set #3

6) Is using a higher concentration local anesthetic, as would be required for cesarean section, acceptable in a patient with multiple sclerosis?

UBP Answer: Complete answer is found in the UBP Practice Set #3

7) You aspirate blood through the catheter and decide to perform a general anesthetic. You are concerned about her airway, but she refuses an awake intubation. How will you induce her?

UBP Answer: Complete answer is found in the UBP Practice Set #3

8) How will you maintain anesthesia?

UBP Answer: Complete answer is found in the UBP Practice Set #3



9) You notice ST depression on the EKG. Would you give nitroglycerine?

UBP Answer: Complete answer is found in the UBP Practice Set #3

10) The ST depression resolves with treatment and the baby is delivered. Following delivery, the uterus is “boggy” and the patient has lost 1400 mL of blood. What would you do?

UBP Answer: Complete answer is found in the UBP Practice Set #3

11) Would you use any other uterotonic agents?

UBP Answer: Complete answer is found in the UBP Practice Set #3


Post-operative Management


1) Five hours after pulling the epidural catheter, the patient is febrile and experiencing back pain and bilateral leg weakness. What do you think?

UBP Answer: Complete answer is found in the UBP Practice Set #3

2) The patient subsequently develops urinary incontinence. What will you do?

UBP Answer: Complete answer is found in the UBP Practice Set #3

3) You determine that her urinary incontinence and leg weakness are the result of relapsing multiple sclerosis. The obstetrician asks you when she can restart her preoperative dose of enoxaparin. What would you tell her?

UBP Answer: Complete answer is found in the UBP Practice Set #3

4) Prior to restarting the enoxaparin, the patient becomes dyspneic. What do you think may be the cause?

UBP Answer: Complete answer is found in the UBP Practice Set #3

5) How is pulmonary thromboembolism diagnosed?

UBP Answer: Complete answer is found in the UBP Practice Set #3

6) Assuming this were pulmonary embolism, how would you treat her?

UBP Answer: Complete answer is found in the UBP Practice Set #3


7) Two days later she is extubated, stable, and complaining of a headache. What do you think?

UBP Answer: Complete answer is found in the UBP Practice Set #3

8) Assuming it is a post-dural puncture headache, how would you treat her?

UBP Answer: Complete answer is found in the UBP Practice Set #3





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