Chestnut Chapter 2- AI Lesson 2

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Questions and Answers

During pregnancy, which lung volume or capacity experiences the most significant increase?

  • Tidal Volume (TV) (correct)
  • Inspiratory Capacity (IC)
  • Residual Volume (RV)
  • Expiratory Reserve Volume (ERV)

Which of the following best describes the change in Functional Residual Capacity (FRC) during pregnancy, and what contributes to this change?

  • FRC increases due to increased chest wall compliance.
  • FRC decreases primarily because of the enlarging uterus. (correct)
  • FRC increases significantly due to hormonal effects on the respiratory muscles.
  • FRC remains unchanged as inspiratory and expiratory volumes balance out.

A pregnant woman is experiencing shortness of breath. Based on the physiological changes of pregnancy, which of the following is the MOST likely contributing factor?

  • Decreased Tidal Volume (TV) reducing overall ventilation effectiveness.
  • Increased Vital Capacity (VC) causing discomfort during deep breaths.
  • Increased Residual Volume (RV) leading to hyperinflation of the lungs.
  • The enlarging uterus decreasing Functional Residual Capacity (FRC). (correct)

How does pregnancy affect Total Lung Capacity (TLC), and what is the primary reason for this change?

<p>TLC decreases slightly due to the reduced Residual Volume (RV). (D)</p> Signup and view all the answers

A physician is evaluating a pregnant patient with concerns about her respiratory function. Which combination of changes in lung volumes and capacities is MOST expected during the patient's third trimester?

<p>Decreased ERV, decreased FRC, and increased TV. (B)</p> Signup and view all the answers

A pregnant patient in her second trimester presents with a grade II systolic ejection murmur at the left sternal border. This murmur is most likely attributed to:

<p>Benign flow murmur due to increased intravascular volume and tricuspid regurgitation. (A)</p> Signup and view all the answers

During pregnancy, cardiac output increases primarily due to an increase in:

<p>Stroke volume, which increases significantly during the first and second trimesters. (A)</p> Signup and view all the answers

Echocardiography in a pregnant woman at 20 weeks gestation is likely to reveal left ventricular hypertrophy characterized by:

<p>Eccentric hypertrophy with an increase in left ventricular mass and unchanged end-systolic volume. (D)</p> Signup and view all the answers

Which of the following valvular changes is LEAST likely to occur as a physiological adaptation during normal pregnancy?

<p>Increase in aortic valve annular diameter. (B)</p> Signup and view all the answers

The point of maximal cardiac impulse (PMI) in a pregnant woman at term is typically displaced:

<p>Superiorly and to the left due to diaphragmatic elevation. (B)</p> Signup and view all the answers

Central venous pressure, pulmonary artery diastolic pressure, and pulmonary capillary wedge pressure during normal pregnancy are typically:

<p>Within the normal nonpregnant range. (D)</p> Signup and view all the answers

The increase in left ventricular end-diastolic volume without a proportional increase in left ventricular filling pressure during pregnancy is best explained by:

<p>Ventricular hypertrophy and dilation accommodating greater volume. (C)</p> Signup and view all the answers

Myocardial contractility during pregnancy is expected to:

<p>Increase, contributing to enhanced cardiac performance. (D)</p> Signup and view all the answers

What is the primary reason for the increase in brachial artery blood pressure observed in some term pregnant women in the supine position?

<p>Compression of the aorta leading to higher systemic vascular resistance. (C)</p> Signup and view all the answers

The supine hypotension syndrome in pregnant women is characterized by which sequence of events?

<p>Tachycardia followed by bradycardia and hypotension. (C)</p> Signup and view all the answers

What is the underlying physiological cause of supine hypotension syndrome in pregnant women?

<p>Profound decrease in venous return and preload. (D)</p> Signup and view all the answers

According to the provided information, how does the lateral position affect intra-abdominal pressure in term pregnant patients?

<p>Significantly lowers intra-abdominal pressure compared to the supine position. (D)</p> Signup and view all the answers

What happens to the inferior vena cava in a term pregnant woman when she lies in the supine position?

<p>It becomes significantly compressed, sometimes completely. (B)</p> Signup and view all the answers

How does collateral circulation contribute to venous return in term pregnant women experiencing caval compression?

<p>It maintains venous return, as reflected by unaltered right ventricular filling pressure in the lateral position. (A)</p> Signup and view all the answers

What percentage elevation above baseline of femoral venous and lower inferior vena cava pressures is consistent with findings by angiography in some term pregnant women?

<p>75% (B)</p> Signup and view all the answers

Which of the following best describes the relationship between BMI and intra-abdominal pressure in term pregnant patients?

<p>Intra-abdominal pressure is elevated in term pregnant patients regardless of BMI. (B)</p> Signup and view all the answers

During the late phase of the third trimester in normotensive pregnant patients, what happens to the Left Ventricular Stroke Work Index (LVSWI) as Pulmonary Capillary Wedge Pressure (PCWP) increases?

<p>LVSWI decreases linearly with PCWP (B)</p> Signup and view all the answers

Based on the cardiac output changes throughout pregnancy, labor and postpartum, when does cardiac output reach its peak?

<p>Immediately postpartum (B)</p> Signup and view all the answers

What percentage change from pre-pregnant levels does heart rate (HR) increase during gestation?

<p>25% (D)</p> Signup and view all the answers

What happens to Systemic Vascular Resistance (SVR) during gestation, and what percentage change does it undergo?

<p>SVR decreases by 20% (D)</p> Signup and view all the answers

Which hemodynamic parameter does not change during gestation?

<p>Left Ventricular End-Systolic Volume (LVESV) (A)</p> Signup and view all the answers

During which period does cardiac output experience the most significant increase relative to pre-pregnancy levels?

<p>Immediately post-partum (A)</p> Signup and view all the answers

According to the figure representing Left Ventricular function, what range of PCWP (Pulmonary Capillary Wedge Pressure) values correlates with a 'normal' LVSWI (Left Ventricular Stroke Work Index)?

<p>PCWP between 5 and 10 mm Hg (C)</p> Signup and view all the answers

What characterizes the pattern of cardiac output change across the trimesters of pregnancy?

<p>Cardiac output increases in the first and second trimesters but slightly declines in the third trimester (D)</p> Signup and view all the answers

If a pregnant patient exhibits a 40% increase in cardiac output during the second trimester, what corresponding change in stroke volume (SV) would likely contribute to this increase, assuming heart rate (HR) remains relatively stable?

<p>A significant increase in SV (D)</p> Signup and view all the answers

Based on the provided figures, how does labor affect cardiac output compared to the third trimester of pregnancy?

<p>Labor leads to a dramatic increase in cardiac output that peaks immediately postpartum (D)</p> Signup and view all the answers

What is the primary hormonal influence on the increase in minute ventilation during pregnancy?

<p>Progesterone, acting as a direct respiratory stimulant. (A)</p> Signup and view all the answers

How does the PaCO2 typically change during the first trimester of pregnancy compared to the nonpregnant state?

<p>Decreases to approximately 30 mm Hg (4.0 kPa). (A)</p> Signup and view all the answers

What is the typical change in tidal volume observed during pregnancy?

<p>Increases from 450 mL to approximately 600 mL. (B)</p> Signup and view all the answers

How does the arteriovenous oxygen difference change as pregnancy progresses?

<p>Increases as oxygen consumption rises and cardiac output increases to a lesser extent. (D)</p> Signup and view all the answers

Why might a pregnant woman in the supine position after mid-gestation have a PaO2 less than 100 mm Hg (13.3 kPa)?

<p>The FRC is reduced due to the enlarged uterus. (D)</p> Signup and view all the answers

What is the expected blood pH level during pregnancy?

<p>Approximately 7.44, indicating slight alkalosis. (A)</p> Signup and view all the answers

By what percentage does alveolar ventilation increase above baseline during pregnancy?

<p>30% to 50% (D)</p> Signup and view all the answers

How does the CO2-ventilatory response curve change during pregnancy?

<p>The slope increases, and the curve shifts to the left. (C)</p> Signup and view all the answers

Why does serum creatinine concentration decrease during pregnancy?

<p>Skeletal muscle production of creatinine remains relatively constant, but the GFR is increased. (B)</p> Signup and view all the answers

What is the typical range for creatinine clearance in a pregnant woman at term?

<p>150 to 200 mL/min (D)</p> Signup and view all the answers

How does the filtration fraction change during pregnancy, and why?

<p>Decreases because the GFR does not increase as rapidly or as much as the renal blood flow. (A)</p> Signup and view all the answers

What happens to blood urea nitrogen (BUN) concentration during the first trimester of pregnancy?

<p>Decreases to 8 to 9 mg/dL. (C)</p> Signup and view all the answers

When do renal hemodynamic alterations typically return to pre-pregnancy levels postpartum?

<p>By 8 to 12 weeks postpartum (D)</p> Signup and view all the answers

What happens to gastric volume during labor?

<p>The mean gastric volume increases. (A)</p> Signup and view all the answers

How does gastric acid secretion change during labor, based on gastric pH levels?

<p>Gastric acid secretion decreases because only 25% of parturients in labor have a gastric pH of 2.5 or lower. (C)</p> Signup and view all the answers

When does gastric emptying return to pre-pregnancy levels after delivery?

<p>By 18 hours postpartum (C)</p> Signup and view all the answers

Flashcards

Grade II Systolic Ejection Murmur

A heart sound often heard during pregnancy at the left sternal border.

Stroke Volume Increase in Pregnancy

Increase in blood pumped by the heart with each beat, rising 20% in the first trimester and 25-30% above baseline in the second.

Left Ventricular Hypertrophy in Pregnancy

Enlargement of the heart muscle, especially the left ventricle, due to increased blood volume and workload.

Cardiac Impulse Shift

The point of maximal cardiac impulse shifts cephalad to the fourth intercostal space and left to at least the midclavicular line.

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Tricuspid and Pulmonic Valve Regurgitation

Dilation of these valves often leads to mild regurgitation. Tricuspid occurs in 94% of term pregnant women.

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Aortic Annulus Changes

The aortic annulus does not dilate from normal pregnancy-induced physiologic changes.

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Increased Myocardial Contractility

Increase in heart muscle contraction strength

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Left Ventricular End-Diastolic Volume in Pregnancy

Left ventricular volume at the end of diastole increases during pregnancy, while end-systolic volume remains unchanged.

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Tidal Volume (TV)

The volume of air inhaled or exhaled during a normal breath.

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Total Lung Capacity (TLC)

The total volume of air in the lungs after a maximum inhalation; decreases around -5%.

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Residual Volume (RV)

The volume of air remaining in the lungs after a maximal exhalation; decreases around -20%.

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Expiratory Reserve Volume (ERV)

The volume of air that can be forcefully exhaled after a normal tidal exhalation; decreases around -25%.

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Inspiratory Reserve Volume (IRV)

The volume of air that can be inhaled after a normal tidal inhalation; increases around +5%.

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Cardiac Output in Pregnancy

Cardiac output increases significantly during pregnancy, peaking in the late second or early third trimester.

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Stroke Volume Increase

Stroke volume increases during pregnancy to contribute to the increased cardiac output.

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Heart Rate Increase

Heart rate increases during pregnancy, contributing to the overall rise in cardiac output.

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SVR Decrease

Systemic vascular resistance decreases during pregnancy due to hormonal changes and the low-resistance uteroplacental circulation.

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LVEDV Increase

Left ventricular end-diastolic volume (LVEDV) increases during pregnancy, reflecting increased preload.

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PCWP Stability

Pulmonary capillary wedge pressure (PCWP) remains relatively unchanged in normal pregnancy.

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LVSWI in Pregnancy

Left ventricular stroke work index (LVSWI) is a measurement of heart performance; during pregnancy LVSWI commonly elevates.

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CVP During Pregnancy

Central venous pressure may increase slightly during pregnancy, but the change is not dramatic.

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PADP During Pregnancy

Pulmonary artery diastolic pressure (PADP) typically remains within normal limits during pregnancy.

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LVESV considerations

Left ventricular end-systolic volume (LVESV) tends to remain unchanged, or may slightly decrease due to increase in EF.

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Angiography

Imaging technique to visualize blood vessels after injecting a contrast agent.

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Venous Pressure Elevation

At term, the femoral venous and lower inferior vena cava pressures increase dramatically in pregnant women.

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Collateral Circulation in Pregnancy

Collateral circulation helps maintain venous return despite caval compression during late pregnancy.

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Intra-abdominal Pressure During Pregnancy

Intra-abdominal pressure is elevated at term, but lower in the lateral position compared to supine.

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Inferior Vena Cava Compression

In the supine position at term, compression of the inferior vena cava is common.

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Brachial Artery BP Increase (Supine)

Some pregnant women experience increased brachial artery pressure when supine due to higher systemic vascular resistance from aortic compression.

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Supine Hypotension Syndrome

Up to 15% of women experience bradycardia and decreased BP when supine.

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Cause of Supine Hypotension

Supine hypotension results from decreased venous return and preload that the cardiovascular system cannot compensate for.

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PaCO2 During Pregnancy

Partial pressure of carbon dioxide in arterial blood. Decreases during pregnancy.

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pH During Pregnancy

Slightly elevated during pregnancy, around 7.44.

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Bicarbonate During Pregnancy

Decreases during pregnancy (around 20 mEq/L).

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Tidal Volume Increase

Increases from 450 to 600 mL during pregnancy.

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Respiratory Rate Increase

Increases slightly (1-2 breaths/min).

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Alveolar Ventilation Increase

Increases 30-50% above baseline, leading to greater oxygenation.

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Progesterone's Respiratory Effect

Acts as a respiratory stimulant, increasing chemosensitivity.

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Gastric Emptying in Labor

Gastric emptying slows during labor and early postpartum, returning to normal ~18 hours postpartum.

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Gastric Acid Secretion

Compared to non-pregnant state, it decreases in early labor.

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Creatinine Clearance in Pregnancy

Increased to 150-200 mL/min, peaking in the first trimester, then declines slightly near term and returns to normal postpartum.

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Filtration Fraction

GFR doesn't increase as rapidly as renal blood flow, causing a decrease in filtration fraction until the third trimester.

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BUN Concentration During Pregnancy

Reduced to 8-9 mg/dL by the end of the first trimester and stays at that level until term.

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GFR Changes in Pregnancy

Early pregnancy increase, peaks in first trimester, declines slightly near term, returns to normal 8-12 weeks postpartum.

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Renin and Aldosterone

Renin and aldosterone levels increase during pregnancy.

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Blood Volume Increase

Increased by approximately 45% to support the growing fetus and increased maternal metabolic needs.

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Study Notes

  • Anatomic and physiologic changes occur during pregnancy to allow adaptation to the developing fetus and its metabolic needs.
  • Recognizing these changes is key to managing pregnant women under anesthesia.

Body Weight and Composition

  • Average maternal weight gain is 17% of pre-pregnancy weight, or about 12 kg.
  • Weight contributed from the uterus and contents accounts for approximately 6kg:
    • Uterus: 1 kg
    • Amniotic fluid: 1 kg
    • Fetus and placenta: 4 kg
  • Approximately 2 kg of weight results from increases in blood volume and interstitial fluid
  • Fat and protein deposition total approximately 4 kg of the weight increase
  • The Institute of Medicine recommends weight gain based on pre-pregnancy body mass index (BMI), reflecting obesity trends
  • A nonobese individual is expected to gain 1-2 kg during the first trimester
  • There is expected gain of around 5-6kg in each of trimesters two and three
  • A long-term increase in BMI is associated with excessive weight gain during pregnancy.

Cardiovascular Changes

  • The heart increases in size due to increased blood volume and stronger contractions.

Physical Examination and Cardiac Studies

Changes during pregnancy include:

  • The expanding uterus raises the diaphragm
  • The first heart sound (S1) is accentuated, with exaggerated splitting of the mitral and tricuspid components
  • Systolic ejection murmur is typical
  • Presence of third (S3) and fourth (S4) heart sounds may occur with no clinical significance
  • The point of maximal cardiac impulse moves toward the left
  • Left ventricular (LV) hypertrophy occurs by 12 weeks' gestation
  • Increase in LV mass increases 23% from the first to the third trimester
  • Increase in LV mass increases by around 50% in final term
  • Diameter in mitral, tricuspid, and pulmonic valves increase
  • Tricuspid and pulmonic regurgitation present in 94% of pregnant women at term
  • Mitral regurgitation present in 27% of pregnant women at term
  • There are no normal dilation changes in the aortic annulus
  • Third trimester electrocardiogram changes:
    • Heart rate steadily climbs during the first and second trimesters
    • The PR and uncorrected QT intervals shorten
    • QRS axis shifts right in first trimester, possibly shifting left in the third
    • ST segments become depressed, and isoelectric low-voltage T waves appear in the left-sided precordial and limb leads.

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