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112 Cards in this Set
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SF62 ANZCA version [2004-Aug] Q125, [2005-Apr] Q18, [Jul07] |
ANSWER A
A - True - Mortality approaches 80%, 90% have cardiac arrest. However, probably due improved vigilance, medical care and inclusion of less severe cases, mortality is now reported as 20-40% B - False - 1:15,000 to 1:50,000 Live Births C - False - 3rd most common in UK and most common cause of direct maternal deaths in Australia, check out http://www.npsu.unsw.edu.au/NPSUweb.nsf/page/md2 ............... or more recent [1] (http://www.npsu.unsw.edu.au/NPSUweb.nsf/page/md3) D - False - neonate 20% mortality, 50% with neurological deficit E - False - Usually occurs during labor but has occurred during abortion, abdominal trauma, and amnioinfusion. |
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What are the risk factors for Amniotic Fluid Embolism?
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1. Maternal age > 35 years, multiparity
2. Placental abnormalities: placenta previa, placental abruption 3. Caesarean delivery or forceps/vacuum assisted 4. Eclampsia 5. Fetal distress, meconium stained liquor 6. Induction/augmentation of labour : strong frequent or tetanic uterine contractions **<20yo appears to be protective **HIstory of AFE is not a RF Timing : 70% during labor 20% during LUSCS 10% following vaginal delviery Can also occur during early gestation second trimester abortions amniocentesis, amnioinfusion abdominal trauma |
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What is the pathogenesis of Amniotic Fluid Embolism?
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Unclear at this stage.
Amnoitic fluid, mucin, fetal cells and hair enter the maternal circulation down a pressure gradient from the uterus to veins. Mainly through small tears in the lower uterine segment and endocervix. 3 proposed theories 1. Mechanical obstruction of materal vasculature by amniotic fluid but this does not explain coagulopathy 2. CLark in 1995 suggested Humoral mechanism : amniotic fluid found to contain inflammatory mediators (bradykinin, prostaglandins, leukotrines, platelet activating factor) which could explain coagulopathy, increased vascular permeability, vasodilation and bronchoconstriction. 1 and 2 largely discarded following discovery that amniotic and fetal cells are common finding in the vasculature of preganant women with no evidence of AFE. 3. Histamine mediated in susceptilbe women similar to septic and anaphylatic shock |
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What is the clinical presentation of Amniotic Fluid Embolism?
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Typically presents during labor and delivery or the immediate postpartum period (5 minutes), but also after
a. blunt abdominal trauma b. cervical suture removal c. transabdominal amniocentesis. Non specific early signs : vomiting, chills, breathlessness. Classical presentation sudden collapse and catastrophic a. cardiovascular collapse : increase in both SVR and PVR, causing a transient hypertension resulting in LVF and Pulmonay oedema. Increasing heart strain, myocardial depression by activated mediator, myocardial ischemia secondary to hypoxemia quickly lead to hypotension and shock. b. respiratory distress : pulmonary vasospasm and LVF result in rapid and profound hypoxaemia, can lead to ARDS type picture c. coaguloapathy : 4 hours post initial presentation, activation of consumputive coagulopathy, rise APTT and PT with fall in fibrinogen, leading to DIC d. fetal compromise |
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What is the incidence of AFE? What is the morbidity and mortality?
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1:8,000 to 1:80,0000
1979, maternal mortality was 80% 2000-2002, triennial report documented mortality of 25% AFE accounts for 10-20% of maternal deaths -most die within first hour of onset of symptoms -85% of survivors have permanent neurological impairment Neonatal mortality is 70% -50% fo survivors will have neurological damage. |
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SF53 [2001-Apr] Q6, [2001-Aug] Q4, [2003-Aug] Q66, [2004-Apr] Q55, [Jul07]
Carbon dioxide is the most common gas used for insufflation for laparoscopy because it A. is cheap and readily available B. is slow to be absorbed from the peritoneum and thus safer C. is NOT as dangerous as some other gases if inadvertently given intravenously D. provides the best surgical conditions for vision and diathermy E. will NOT produce any problems with gas emboli as it dissolves rapidly in blood |
ANSWER C
A : although CO2 is cheap and readily available, it is not the reason we use CO2. B : CO2 is absorbed quickly across peritonium, resulting in high PaCO2 and respiratory acidosis C : CO2 is highly soluable in blood, therefore gas emolization is less severe and with treatment rapid dissolution of emboli. He, Air and N2 dissolve less rapidly and carry a higher risk of lethal venous emobli. D : false, argon or helium would be better. E : false, it will produce problems, but severity will be less and emobli dissolve quicker, CO2 is 50 times more soluable then He. Ideal insufflating agent : colorless, non combustable, non explosive, physiolgocially inert and readily soluable HELIUM and N2 Pro : inert, no acid-base effects Cons : poor blood gas solubility making embolism life threatening, require special inline set up N20 Pro : less post op pain, well tolerated hemodynamically Con : combustion ARGON Pro : inert, slightly less soluable than CO2 Con : rare gas, difficult set up |
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SF11 [1988] [Aug95] [Apr97] [Jul97] [Apr98] [Apr99] [2001-Apr] Q61, [2004-Apr] Q102, [2005-Apr] Q91, [2005-Sep] Q89
Factors which do NOT contribute to the increased risk of aspiration pneumonitis during pregnancy include A. increased gastrin production B. a tendency for the stomach to be pushed up against the left diaphragm C. increased acidity of gastric secretion D. increased volume of gastric secretion E. decreased secretion of the hormone motilin |
ANSWER E
A - Gastrin is produced by placenta during pregancy. Causing hypersecretion of gastric acid. Nearly all parturients have gastric pH under 2.5, and over 60% have gastric volumes greater than 25 mL. B : stomach is pushed anterior and superior against left hemidiaphragm C : See A D : See A E : mixed reports in the literature, levels may or may not change, but they are not clearly associated with an increased risk of aspiration |
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SF What increases the risk of threading an epidural catheter into a blood vessel?
A. not doing a CSE B. injecting saline prior to threading catheter C. LOR to saline instead of air D. paramedine instead of midline approach E. sitting position instead of lateral |
ANSWER E
A - it is thought that CSE decreases risk by ensuring catheter is midline, but no documented research. B : LOR NS decreases risk by distenting epidural space. OR 0.45 LOR NS vs LOR air. C : See B D : no difference (only 1 RCT showing this, ?insufficient data) E : epidural vein engorgement/ distention is greater when sitting instead of lateral position. Risk of epidural vein cannulation is higher in sitting position. Anesth Analg 2009;108:1232–42 : Metanalysis of 7 techniques in obstretric women 1. position : supine vs sittting OR 0.53 6 RCT 2. approach : paramedian vs midline no difference 1 RCT 3. touhy size : 16 vs 18 no difference 1 RCT 4. LOR technique : NS vs air, OR 0.45 8 RCT 5. oriface catheter : single vs multi OR 0.64 5 RCT 6. wire embbeded catheter 1 RCT 7. limiting catheter insertion to 6cm, >7cm OR 0.27 3 RCT |
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Outline your management of AFE.
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IMMEDIATE MANAGEMENT
Key Factors -early recognition -prompt resuscitation -delivery of fetus -input of consultants : anaesthetist, obstetrician, hematologist, intensivist Oxygenation -maintain oxygenation -due to high maternal oxygen consumption and reduced FRC, desaturation occurs rapidly with significant neurological morbidity to mother and baby. -intubate early by experienced clinician due to potential difficult airway. -assist ventilation with PEEP Haemodynamic -rapid IV filling -direct acting vasopressors -inotropes if required -CPR with left uterine displacement -bimanual compression if bleeding results until surgical intervention -anticipate haemorrhage : insert large bore IVC, order blood products early Uterine tone -maintained using oxytocin, ergometrine and prostaglandins (misoprostol) -bimanual or uterine packing if required Coagulation -consumptive coagulopathy should be anticipated -consult haemotologist early -plasma, cryo, platelets -recombinant factor VII Delivery of baby -CPR, surgical delivey within 5 min for improved maternal outcome ICU MANAGEMENT -supportive -steriods -prostacyclin or nitric oxide to improve oxygenation with ARDS -ballon pump to assist LVF -plasma exchange/haemofiltration to removed amniotic fluid debris -ECMO |
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Differential diagnosis for maternal collapse?
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Pregnancy specific
-AFE -acute haemorrhage -Uterine rupture -Eclampsia -Peropartum cardiomyopathy Anaesthetic Specific Diagnosis -high regional block -local anaesthetic toxicity Non obstretic causes -pulmonary emobolism -air embolism -anaphylaxis -sepsis -cardiac ischemia -arrhythmia -transfusion reaction |
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SF01 Best immediate treatment of severe post-partum haemorrhage after delivery of a complete placenta:
A. IV Ergometrine B. Blood transfusion C. Evacuation of uterus without blood transfusion D. Bimanual compression of the uterus E. Aortic compression |
ANSWER A
All answers are correct, but the 'best immediate treatment' |
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SF88 [Mar10] [Aug10] Maternal cardiac arrest. In making the diagnosis of amniotic fluid embolism, large amount of PMNs surrounding foetal squamous cells are
A. Pathonomonic B. Supportive C. Only found at postmortem D. Irrelevant E. Incidental |
ANSWER B
No diagnostic test for AFE, it is diagnosis of exclusion. Non specific tests FBE : anaemia, thrombocytosis Coag : consumptive coagulopathy ABG : hypoxemia, low Pa02 to FiO2 ratio CXR : early ARDS ECG : strain, arrythmias Diagnostic test -cytological analysis of central venous blood and broncho-alveolar fluid -Sialyl tn antigen test -zinc coproporphyrin -serum tryptase levels all are non specific and only suggestive of AFE |
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F87 [Mar10] [Aug10] Labour epidurals increase maternal and foetal temperature. This results in neonatal:
A. Increased sepsis B. Increased investigations for sepsis C. increased non shivering thermogenesis D. Increased need for resuscitation E. Cerebral palsy |
ANSWER B
Chestnut's Obstetric Anesthesia: Principles and Practice (4th Edn), Chestnut et al. 2009; p457. Labour epidural analgesia is associated with an increase in maternal core body temperature, but also with an increased neonatal temperature and fetal heart rate. Several studies have shown that labour epidural analgesia is associated with increased neonatal neonatal sepsis evaluations, but no increase in neonatal sepsis. |
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SF86 [Mar10] Most common cause of maternal cardiac arrest
A. Pulmonary embolism B. Amniotic fluid embolism C. Haemorrhage D. Preeclampsia E. Cardiomyopathy |
ANSWER B
CEMACH |
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SF84 [Apr07] Q112
Analgesic requirements during labour are reduced by each of the following except A. Acupressure B. Acupuncture C. Hypnosis D. One to one support by midwife E. TENS |
ANSWER A
AMPSE : "complementary and other methods of pain relief in labour" Midwife/support person one on one- reduces analgesic use (level 1) hypnosis- decreased requirement for phar,acological analgesia (level 1) acupunture- decreased need for analgesics (level 1) TENS- "evidence of a weak opioid sparing effect" (level 1) no mention of acupressure 'Analgesia in labour: non-regional techniques' Caroline Fortescue, Michael YK Wee BJA CEA CCP Volume 5 Number 1 2005 p9-13 * Acupuncture (Acupressure, laser acupuncture) - One RCT of 100 women in Sweden comparing acupuncture with no acupuncture suggested former group needed less analgesia, including epidurals * Hypnosis - Cochrane review of three RCTs: one reported less anaesthesia and another less narcotic use, but overall meta-analysis showed no difference in the need for pain relief * Continuous support - Cochrane review of 15 RCTs involving 12 791 women. Those with continuous support, as opposed to conventional care, were less likely to have intrapartum analgesia, operative birth or be dissatisfied with their experiences * TENS - Systematic review of eight RCTs failed to demonstrate analgesic effect |
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SF 38yo obese female with DM, other comorbidities, undergoing LSCS with spinal anaesthetic with a 27G Whitacre needle, having this and that, blah, blah. then two days later complains of numbness on a small patch on lateral aspect of mid-thigh. On full neuro exam - no other signs/symptoms.
A. conus medullaris injury B. L2 nerve root compression C. L3 root lesion D. L4 root lesion E. meralgia paraesthetica |
ANSWER E
A : Conus medullaris ends at L1/L2 Sudden bilateral pain with dural puncture, Reflex : knee jerk preserved, ankles affected Radicular pain : minimal Lumbargo : severe Sensroy : saddle numbness, symmetrical and bilateral Motor : symmetric, hyperreflexic distal paresis Sphinter dysfunction E: Meralgia Paresthetica Mono neuropathy of lateral cutaneous nerve (purely sensory over anterolateral thigh, no motor) Focal entrapment as it passes through inguinal ligament Causes : DM, pregnancy, tight clothing, obesity, fetal position Treatment is conservative, lignicaine + steriod injection if paraesthesia is bad. |
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SF (Q105 August 2008) A 25yo primipara with an uncomplicated pregnancy presents to delivery suite in labour at term. Her membranes spontaneously rupture soon after, and it is blood-stained. At the same time, a severe foetal bradycardia appears on the CTG. What is the most likely cause of this?
A. Placenta accreta B. Placental abruption C. Uterine rupture D. Vasa praevia E. True knot in the umbilical cord |
ANSWER D
A : Placenta Accreta -abnormally deep attachment of the placenta, through the endometrium and into the myometrium -bleeding occurs when placenta removed post birth **Cause of PPH -1:2,500 pregnancy -very rarely recognized before birth, and is very difficult to diagnose Placenta Increta - invasion past myoemtrium Placenta Percreta - invasion through uterine serosa into neighbouring organs (bladder) RF - uterine surgery, LUSCS, myomectomy B : Placental Abruption -abnormal separation of placenta from uterine wall 20 weeks after -symptoms : pain, pallor, fetal distress, raising fundus (continued bleeding) -in severe cases PV bleeding -RF : maternal hypertension, abdominal trauma, short umbilical cord, prolonged ruptured of membranes, <20 >35, prev abruption C : Uterine rupture -usually during labor -integrity of myometrium breached -similar presentation to placental abruption, but pain and bleeding follow fetal distress -RF : LUSCS, previous uterine surgery, induction, high parity D : Vasa Praevia The classic triad are membrane rupture followed immediately by painless vaginal bleeding and fetal bradycardia E : True Knot Painless Fetal distress |
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SF (Q141 Aug 2008) Patient with placenta acreta. Surgical management MOST likely to save her life
A B lynch suture around the uterus for external tamponade B Rusch balloon in the uterus for internal tamponade C ligation of the internal iliac arteries D ligation of the uterine arteries E subtotal or total hysterectomy |
ANSWER E
Tricky question. A : B-Lynch Suture - Developed in 1997 by B Lynch. Heavy suture that envolopes and mechanically compress an atonic uterus in severe PPH, not yet used much in SE asia. No data so far to suggest usefulness in Placenta Acreta. B : Rusch balloon -used for atony or lower segment bleeding C : Ligation of internal iliac arteries -high rate of failure 50% as uterine arteries still bleeding D : Ligation of uterine arteries -high rate of failure 50% as internal iliac still bleeding E : subtotal or total hysterectomy -indicated if accreta is diagosed before delivery. -hysterectomy is performed with placenta still intact |
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SG53 During laparoscopic surgery, pneumoperitoneum usually results in a fall in cardiac output when intra-abdominal pressure exceeds
A. 10 mmHg…. B. 20 mmHg C. 30 mmHg D. 40 mmHg E. 50 mmHg |
ANSWER B
Reference CEACCP 2004, V4,107: IAP < 10 mm Hg: increases VR, increases CO IAP 10–20 mm Hg decreases VR, decreases CO BUT increases SVR and therefore BP unchanged or increased IAP > 20 mm Hg greater decrease VR, greater decrease CO, so decreases BP |
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True of False
1. Regional anaesthesia is impossible with laboring women with scoliosis. 2. Routine fluid loading is not required with low dose techniques as hypotension is uncommon. 3. CSA is inferior to epidurals |
1. False
Thoraco-lumbar scoliosis if 4 times more common in females (incidence 2%) Corrective surgery has improved recently, but older posterior approach obliterates or distorts epidural space with fibrous scar tissue, blood clot or metalwork crossing the midline. Cephalo-pelvic disproportion is increased in scoliosis therefore instrumentation and LUSCS increased 2.5 fold Disadvantages include technical difficulties identifying epidural space, patchy/poor analgesia, inadvertant subdural or intrathecal catheter placement and subsequent PDPH Techniques to find epidural space 1. Gain access to epidural space below surgical scar 2. CSE 3. CSA Case reports indicate successful placement in 50% of women with scoliosis 2. TRUE Level 1 evidence that hypotension is uncommon Low dose is 25mg bupivacaine Higher doses will require IV prelaoding as incidence of hypotension increases 3. False CSA is associated with better early analgesia, less motor block, higher maternal satisfaction However, pruitus is more common and technically more difficult, with higher failure rates. |
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Describe your technique for Continuous Spinal Anaesthesia.
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In 1992, multiple cases of cauda equina syndrome associated with micro-catheters due to hyperbaric lodicaine solution lead to withdrawal of micro-catheters from US market
Advantages -level can be titrated -slow gradual administration -reduced risk of high spinal -reduced risk f cardiovascular instability Equipment 1. 22G Spinocath Catheter 2. 27G Needle Position : Sitting or lying Method : routine spinal Over the needle technique 3cm into space CSA regimen for labor Initial dose 1ml of 0.25% plain bupivacaine plus 15ug fentanyl 1ml increments of 0.25% plain buprivacine every 5 min until pain free Subsequent 1ml doses every 45-60min CSA regimen for LUSCS 1ml of 0.5% hyperbaric bupivacaine with 15ug fentanyl Further 1ml of 0.5% bupivacaine until block sensory block reaches T5 |
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Epidurals True or False
1. Inadvertent dural puncture occurs in approximately 1% of regional blocks 2. Bloody Tap occurs in initial epidural intravenous placement occurs 6% and be removed 3. Pruitis, paresthesia and backpain are more common with CSE than with epidural analgesia 4. The incidence of PDPH is greater with CSE 5. Accidental dural puncture is more common in NSLOR rather than air. |
1. TRUE; Pan et al 2004
2. FALSE 6% of epidural catheters are placed intravenously as detected with bloody tap, but 46% re made functional by retracting 1-2cm 3. TRUE Incidence of paresthesia 60% CSE is a RF for backpain 4. FALSE Although the dura is punctured, the rates of headache is not increased because a. very fine gauge needle b. epidural catheter + solution increases epidural pressure =reduced risked for dural leak 5. FALSE ADP NSLOR 0.69% ADP ALOR 1.11% |
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Describe the COMET study
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Comparative Obstetric Mobile Epidural Trial
RCT Conducted in the UK between 1999-2000 Compared 3 groups 1. Epidural 0.25% bupivacaine infusion 2. Low-dose CSE followed by epidural low dose boluses 3. Low-epidural infusion Findings 1. Normal vaginal delivery lower in higher concentration epidural infusion (1. 35%, 2. 43%, 3. 43%) 2. Higher rates of instrumentation 3. Worse APGAR scores Interpretation Low dose epidural techiques for labor analgesia has benefits for delivery outcome for mother and baby. NOTE PCEA has been recently established as preferred mode of epidural drug delivery 1. decrease in local anaesthetic consumption without compromising analgesia 2. lower rate of top-up boluses 3. increase maternal and midwife satisfaction 4. lower rates of motor block less rates of instrumentation |
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Describe the stages of labor.
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Stages of Normal Labor
Stage 1 (s1) 0cm to Fully Dilated -includes both latent and active phases -Latent phase : prodromal labor, cervical effacement occurs (thinning and stretching of cervix), ends with the onset of active first stage, when cervix is 3cm dilated -Active phase : cervical dilation, cervical effacement followed by descent of presenting part -Graded by Bishop Score : Position, Consistency, Effacement, Dilation, Fetal Station; -Score <5 suggest labor is unlikely to start without induction -Score >9 suggest labor will occur spontaneously Seond Stage : fetal delivery -flexion -descent -rotation of presenting part Third Stage : Delivery of placenta |
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What is the mortality asssociated with the different modes of delivery?
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Vaginal Delivery : 1.7 per 10,000
Elective CS : 2.9 per 10,000 Urgent CS : 10.2 per 10,000 Emergency CS : 20 per 10,000 |
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What are the fetal risks with delivery?
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Risk of Neonatal Encephalopathy defined as difficulty initiating and maintaining respiration, depression of tone and reflexes, subnormal consciousness and often seizures
1. Acute intrapartum event OR 4.4 2. Operative VD OR 2.3 3. Emergency CS OR 2.2 4. Elective CS OR 0.17 Neonatal Intrancranial Injury (compared to NVD) Vacuum OR 2.7 Forceps OR 3.4 CS OR 2.5 Rates of birthday injuries (fractures and nerve injuries) reduced by 50% with CS Perinatal transmission of HIV, Hep B, Hep C, HSV and HPV reduced with elective CS |
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SF56 ANZCA version [2002-Aug] Q109, [2003-Apr] Q75 [Mar06]
In preeclampsia A. once delivery of the placenta takes place, the condition improves B. in the absence of other risk factors a platelet count of greater than 50 is adequate for epidural anaesthesia C. corticosteroid therapy has no effect on the severity of thrombocytopenia D. magnesium sulphate halves the incidence of eclampsia E. spinal anaesthesia contraindicated |
ANSWER A
A. FALSE : after delivery of the placenta, pre-eclampsia usually improves, can take 3 months to improve. B. FALSE : Obstetric Anaesthesia Scientific Evidence from ANZCA gives 75 as a safe figure, but must be balanced against operator experience and other clinical risk factors for coagulopathy C. FALSE : Consistent with observational studies, dexamethasone was shown to significantly increase the platelet count. This however did not translate to improvement in outcomes and the clinical relevance of this is unclear. D. TRUE : Magnesium sulphate halves the risk of eclampsia, and probably reduces the risk of maternal death. There do not appear to be substantive harmful effects to mother or baby in the short term." From MAGPIE. E. FALSE : Regional blockade is the preferred method of anaesthesia for caesarean section (Level II). There is currently insufficient evidence to support any specific type. |
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SF57 ANZCA version [2003-Aug] Q143, [2004-Apr] Q66, [Mar06]
During elective caesarean section under spinal anaesthesia A. maternal hypotension requiring intervention is infrequent B. the duration that the maternal systolic blood pressure is below 100 mmHg is of less importance for producing adverse cord blood acid-base measures than the degree of fall in systolic blood pressure C. there is a significant difference between the use of rescue boluses compared to infused prophylactic ephedrine on the status of cord blood acid-base measures D. there is less nausea and vomiting if ephedrine is prophylactically infused compared to using it as a rescue bolus to treat any maternal hypotension when it does occur E. there is no adverse effect from maternal hypotension on cord blood acid-base values |
ANSWER D
A. FALSE : Hypotension is defined as SBP<100 or decrease in SAP 10-30%. Incidence of hypotension during spinal LSCS is 80-90%. It is associated with hypotension which influences uterine blood flow. Roberts et al and Mueller et al have documented higher rate of retal acidemia after regional anaesthesia for elective LUSCS. B. FALSE : marked or prolong hypotension are likely to be assocated with fetal asphyxia and/or acidosis. However, the degree and duration of hypotension that is likely to be harmful to the fetus in humans is undetermined C. FALSE : fetal cord blood pH shown to be lower in a dose dependant manner. However, rescue compared to infused showed no difference in cord pH D. TRUE D. TRUE E. FALSE |
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Acute tocolysis in labour
Indications Drugs and doses |
Tocolysis refers to the suppression of preterm labor to delay delivery.
Indications 1. Pre-term labor in an otherwise uncomplicated pregnancy a. to extend delivery past 37 weeks : pre term labor is a major contributor to perinatal mortality and morbidity especially before 34 weeks b. enable manipulations for breech or transverse lie c. allow intra-uterine transfer to tertiary centre with NICU support Short-term tocolysis to enable a. administration of steroids b. intra-uterine transfer to tertiary centre c. fetal distress to allow emergency LUSCS Intraoperative (LSCS) a. ease fetal extraction b. inverted uterus Contraindications : any contraindication to prolonged labor -known lethal congenital or chromosomal malformation -intra uterine infection -severe preclampsia - placental abruption -advanced cervical dilation Terbutaline: -250 micograms IV or SC: Recommended at the Royal Women's Hospital * The ampoule comes as 500mcg/1ml. The volume to be given is therefore 0.5ml IV if there is already IV access, or 0.5ml SC if there is not. IV Salbutamol: 100 micrograms IV * Make up 1 ampoule of salbutamol sulphate for injection 500 µg (NOT Ventolin Obstetric), to 10 ml in normal saline (final concentration 50 µg/ml) * Administer 100 µg (2 ml of the preparation, above) over 1-2 minutes * May be repeated after 5 minutes if hypertonus sustained Sublingual GTN spray: 400 µg * Product in form of sublingual spray (Nitrolingual ®) * One metered spray (=400 µg) administered under the tongue * If response is inadequate, repeat the dose after 5 minutes * If FHR tracing is non-reassuring, and tocolysis (as above) ineffective Magnesium Infusion Nifedipine -Initial dose of 20mg -Followed by 10-20mg 3-4 per day -adjust according to degreee of uterine relaxation -use only for 48 hours Atosivan (oxytocin receptor anatagonist) -initial dose of 6.75mg IV over 1 minute -infusion 18mg/hour for 3 hours then 6mg/hour for up to 45 hours (2 days) Indomethecin |
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SF59 ANZCA version [2004-Apr] Q142, [2004-Aug] Q75, [Mar06] Q63, [Jul06] Q51
Multiple sclerosis in pregnancy is A. a contraindication for epidural anaesthesia in labour B. a contraindication for the use of suxamethonium C. associated with an increased caesarean section rate D. associated with an increase in relapse rate postpartum E. associated with a worse fetal outcome |
ANSWER D
A - False - Neuraxial blockade is associated with exacerbations but epidural analgesia for labour is not contraindicated as long as local anaesthetic concentrations are kept to a minimum B - False - Relative contraindication and is dependent on the magnitude of denervation/disability as to the K efflux from sux. Sux should be avoided. D - True o Pregnancy appears to have a relatively protective effect on women with MS. The number of MS exacerbations is reduced during pregnancy, especially in the second and third trimesters o Exacerbation rates may rise in the first three to six months postpartum, and the risk of a relapse in the postpartum period is estimated to be 20-40% |
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SF77 ANZCA version [2005-Sep] Q40, [Mar06] Q36
Epidural analgesia in labour A. typically increases uterine perfusion in healthy women B. can result in lateral rectus muscle palsy if complicated by dural puncture C. is particularly indicated for mothers with aortic stenosis D. may cause hyperglycaemia in the presence of diabetes mellitus E. may be lethal in the presence of maternal mitral stenosis if, following delivery, the block is prolonged |
ANSWER B
Answer: B (C - epi can be done, but not particularly indicated for) • A. False - "Continuous epidural analgesia with bupivacaine 0.075% increases the resistance of uterine artery and therefore possibly reduces the uterine blood flow" • B. True - We believe that a dural puncture during an attempted epidural anesthetic resulted in cerebrospinal fluid (CSF) leakage with a consequent headache. The CSF leak caused traction on the sixth cranial nerve resulting in lateral rectus muscle palsy. An epidural blood patch performed after the onset of symptoms did not acutely resolve the abducens nerve palsy." o 'The complications of accidental dural puncture include headache, high or total spinal anaesthesia, 6th cranial nerve palsy and subdural haemorrhage. • C. True -traditionally contraindicated but now considered safe - epidural for labour indicated in AS. Epidural, CSE and spinal also been safely used in patients with AS for caesarian section • D. False - Epidural reduces the stress in labour and enables better glucose control, therefore is indicated. • E. ?False - epidural indicated for labour in MS. Epidural and CSE also used for C/S. No evidence found for mortality after prolonged block, no mention early removal. |
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SF82 [Mar06] Q145
Lumbar epidural analgesia in labour using 0.125% bupivacaine A. improves FVC (forced vital capacity) if the upper sensory level is kept below T12 B. improves FVC and FEV1 (forced expiratory volume in one second) if upper sensory level is kept below T12 C. improves FVC, even if the sensory level is above T10 D. improves FVC and FEV1, even if the sensory level is above T10 E. reduces FVC and FEV1 if the sensory level is above T10 |
ANSWER D
Seems to be based on a study from Anaesthesia Volume 59 Page 350 - April 2004 The effect of epidural analgesia in labour on maternal respiratory function. The respiratory function measurements were taken with mothers completely PAIN FREE, so must have had a block to T10: "As soon as a sensory blockade above T10 was obtained, we started a continuous infusion of 10 ml.h−1 bupivacaine 0.125% with fentanyl 0.0001%...The upper sensory level of epidural analgesia was T8 (T6–T8[T4–T10])" from above article. FVC, FEV1, and PEF all improved. |
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SF39 ANZCA version [2004-Apr] Q15, [2005-Sep] Q27, [Mar06] Q35
Complications of diabetes mellitus in the pregnant patient include each of the following EXCEPT A. increased risk of oligohydramnios B. greater risk of foetal death in the third trimester C. retinopathy and retinal detachment D. potentiation of hypotension when regional anaesthesia is administered to assist delivery E. reduced foetal oxygen delivery |
ANSWER A
Complications of Diabetes mellitus for baby: 1. increased fetal malformations, persists despite better treatment of T1DM. two- to sixfold increase in major malformations. Mainly neurological (neural tube), cardiac and sacral. 2. supply demand relationship affects: maternal vasculopathy, preeclampsia, hyperglycaemia and DKA causing poor placental perfusion AND the fetus has increased metabolic needs due to hyperinsulinism and macrosomia. 3. stillbirth previously occurred in 10-30% of T1DM, usually after 36weeks, thought to be due to chronic intrauterine hypoxia. 4. fetal umbilical cord blood samples from pregnant women with type 1 diabetics have demonstrated "relative fetal erythremia and lactic acidemia." 5. macrosomic children: birth trauma, obesity when older 6. neonatal hypoglycaemia 7. respiratory distress syndrome 8. polycythaemia and jaundice 9. Ca and Mg metabolic changes |
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RB38d ANZCA version [2006-Mar] Q111
Post partum foot drop is most frequently caused by A. compression of the lumbosacral trunk by the foetal head or forceps B. damage to the common peroneal nerve from lithotomy position C. damage to the conus medullaris by misplaced spinal anaesthesia D. L4 Nerve root damage from epidural analgesia E. the excessive lumbar lordosis of pregnancy stretching nerve roots |
ANSWER A
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RB38c ANZCA version [2003-Aug] Q131
A woman has an epidural placed for forceps delivery after a prolonged second stage of labour. The next day she has a right foot drop, and numbness over the anterior part of her lower leg and the dorsal surface of her right foot. The most likely cause is A. L4 nerve root lesion from trauma during epidural placement B. L5 nerve root lesion from trauma during epidural placement C. L5 nerve root lesion from an acute disc protrusion D. right common peroneal nerve lesion from compression by lithotomy stirrups E. right lumbar plexus lesion from compression by the fetal head |
ANSWER E
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RB38b ANZCA version [2002-Aug] Q124
A woman has an epidural placed for forceps delivery after a prolonged second stage of labour. The next day she has a right foot drop, and numbness over the anterior part of her lower leg and the dorsal surface of her right foot. The most likely cause is A. right common peroneal nerve lesion from the use of stirrups in the lithotomy position B. right L5 nerve root lesion from the epidural placement C. right lumbar plexus lesion from compression by the fetal head D. L5 nerve root lesion from a disc protrusion E. transient neurological symptoms (TNS) syndrome |
ANSWER C
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PZ127 ANZCA Version [2006-Mar] Q136
Nonsteroidal anti-inflammatory drugs given during pregnancy, have been associated with all of the following EXCEPT: A. foetal cardiac complications if given in late pregnancy B. foetal renal complications if given in late pregnancy C. increased production of amniotic fluid D. increased risk of miscarriage E. persistent neonatal pulmonary hypertension |
ANSWER C
This is directly form the ANZCA Acute Pain Book. All the answers there under section "The Pregnant Patient". Foetal cardiac and renal problems with late use of nsaids, realtively safe in early pregnancy, should be discontinued by 32nd week. Definitely wrong one is increased amniotic fluid production. |
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SF80 ANZCA Version [2006-Mar] Q138
In relation to nausea during obstetric regional anaesthesia A. atropine is more effective treatment than vasopressors when there is a high spinal block B. nausea is worse with phenylephrine infusion compared to ephedrine infusion C. phenylephrine increases the emetic effect of decreased preload D. metoclopramide is the treatment of choice E. ondansetron is the treatment of choice |
ANSWER A
Nausea and vomiting may have been secondary to an absolute, or relative, increase in vagal tone. There is evidence for a vagal mechanism causing nausea during spinal anesthesia. Atropine has been found to be more effective at treating nausea associated with high spinal anesthesia than vasopressors. More recently, glycopyrrolate has been found to reduce nausea during spinal anesthesia for cesarean delivery |
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SF79 ANZCA Version [2006-Mar] Q140
Regarding the use of adrenergic drugs to maintain normotension during regional anesthesia for elective caesarean section A. alpha-adrenergic agonists are associated with increased fetal acidosis B. alpha-adrenergic agonists are associated with reduced uteroplacental perfusion C. ephedrine increases fetal heart rate and catecholamine levels D. phenylephrine is associated with increased nausea and vomiting compared with ephedrine E. prophylactic ephedrine decreases the incidence of fetal acidosis |
ANSWER C
Either phenylephrine, metaraminol or ephedrine may be used for the management (prevention and treatment) of hypotension during spinal anaesthesia in obstetrics.A recent quantiative systematic review of controlling trials comparing ephedrine with phenylephrine found NO difference between the 2 drugs in their ability to manage hypotension, except for a higher incidence of maternal bradycardia with phenylephrine. There was NO difference between the two vasopressors in the incidence of foetal acidosis (umbilical pH <7.2) |
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PH59 ANZCA version [Jul 06] Q58
In a normal pregnant woman laboratory tests would show: A. an arterial pH of 7.4 B. an increase in functional residual capacity (FRC) C. decreased oxygen consumption D. an arterial base excess of +5mmol.l-1 E. a PaCO2 of 50 mmHg |
ANSWER A
To quote KB: "This is the only example of full acid-base compensation in normal physiology." * pH increases to 7.41-7.46 A&IC 33:2 p168 table (2005). * FRC decreased during pregnancy * pCO2 decreased to 30-32 mmHg |
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SF72 ANZCA Version [Jul06] Q147, [Apr07]
A 38-year-old primigravida presents with progressive dyspnoea in late pregnancy. The strongest indicator for further investigation would be A. a 2/6 systolic ejection murmur B. a raised JVP (jugular venous pressure) C. a third heart sound D. orthopnea E. peripheral oedema |
ANSWER B
normal changes -increase in end-diastolic chamber size -increase in total L ventricular wall thickness -CVP unchange -asymtomatic pericardial effusion -an innocent grade I or II systolic heart murmur -S3, or S4 in late pregnancy -ECG: increase in benign dysrhythmias, reversible ST, T and Q wave changes and some L axis deviation. indication of heart disease: -systolic murmur greater than grade III -any diastolic murmur -severe arrthymias -unequivacol cardiac enlargement on x-ray. -presence of congestive heart failure is suggested by hepatomegally and jugular venous distension paroxysmal nocturnal dyspnoea, chest pain, nocturnal cough, new regurgitant murmurs, pulmonary crackles, elevated jugular venous pressure and hepatomegaly. |
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SF73 ANZCA Version [Jul06] Q146, [Apr07] Q145
Drugs that may be used for the management of heart failure, secondary to dilated cardiomyopathy in pregnancy, include each of the following EXCEPT A. ACE (angiotensin-converting enzyme) inhibitor B. beta-blockers C. digoxin D. loop diuretics E. nitrates |
ASNWER A
* A. ACE (angiotensin-converting enzyme) inhibitor - true: Category D * B. beta-blockers - false: Oxyprenolol routinely used for pregnancy induced hypertension. Category C * C. digoxin - false: Category A * D. loop diuretics - false: Category C * E. nitrates - false: Cat B2 |
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SF74 ANZCA Version [Jul06] Q140
Immediately following delivery by caesarean section under regional anaesthesia a previously healthy primigradiva complains of chest pain and breathlessness, and then becomes unconscious. The most likely diagnosis is A. accidental administration of suxamethonium B. air embolism C. amniotic fluid embolism D. anaphylaxis to syntocinon E. pulmonary thromboembolism |
ANSWER B
This is a previously healthy patient who suddenly develops chest pain and breathlessness. I don't have any specific references, other than memory of a tutorial at the Royal Hospital for Women, at which the presenter emphasised that the time immediately following delivery has a high risk for venous air embolism, especially if the uterus is exteriorised, due to the large number of vessels open to atmosphere at this stage |
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SF12 ANZCA version [2002-Mar] Q22, [2002-Aug] Q50, [2004-Aug] Q60, [2005-Apr] Q63, [Apr07], [Mar10]
Supine hypotension during late pregnancy is associated with A. a rise in the systemic vascular resistance B. a rise in the cardiopulmonary blood volume C. increased heart rate D. stable stroke volume E. a rise in the cardiac index |
ANSWER C
The concept of aortocaval compression & supine hypotension are different. While all pregnant women compress the aorta & vena cava on supine position, not all women become hypotensive. "Supine hypotension" (or supine hypotension syndrome - SHS ) only occurs in 8% of women. It occurs because these women have not developed sufficient pelvic collaterals to assist venous return on caval compression. SHS is defined as a 15-30 mmHg reduction in systolic BP with a SUSTAINED ELEVATION OF HR of > 20 bpm. Ref: “Hemodynamic changes & baroreflex gain in the supine hypotension syndrome”; American Journal of Obstetrics & Gynaecology 2002: 187; 1634-4 SHS is most commonly due to CAVAL compression. Aortic compression and neurogenic etiologies are less common causes. Ref: Uptodate - Maternal cardiovascular & hemodynamic adaptation to pregnancy" Hence aortic compression is not a uniform feature of SHS, but caval compression is. The increased in SVR due to increased SNS outflow may not occur in pregnant women because they are maximally vasodilated & the aorta may not be compressed. |
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AC151 ANZCA Version [Jul06] Q112, [Apr07]
Which of the following contributes the LEAST to motor neuropathy following the lithotomy position? A. age B. BMI (body mass index) >25 C. diabetes D. peripheral vascular disease E. smoking |
ANSWER B
* Surgical Factors * Improper lithotomy position * Extreme high lithotomy position * Prolonged maintenance of lithotomy (>2 hours) * Patient Factors * Hypotension * Thin body habitus * Old age * History of vascular diseasae * Diabetes * Smoking |
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SF71 ANZCA version [2005-Sep] Q103, [Apr07] [Jul07]
Best evidence in obstetric anaesthesia supports each of the following assertions EXCEPT A. colloid prevents hypotension from regional anaesthesia more effectively than crystalloid B. fentanyl added to spinal bupivacaine for caesarean section has no influence on the incidence of intraoperative nausea C. high doses of ephedrine (>15 mg) are more likely to cause hypertension than prevent hypotension D. in labour, combined spinal-epidural analgesia is associated with faster onset and greater maternal satisfaction than epidural analgesia E. in nulliparous women, epidural analgesia in labour, compared with intravenous opioid analgesia, does not increase caesarean section rate |
ANSWER B and D (both wrong)
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SF55 ANZCA version [2002-Aug] Q105, [2003-Apr] Q69, [2004-Aug] Q88, [2005-Sep] Q101, [Apr07] Q141,
In relation to obstetric haemorrhage A. amniotic fluid embolism is unlikely to present as unexplained haemorrhage B. coagulopathy is uncommon, when severe abruption leads to maternal shock and fetal death C. the risk of placenta accreta, but NOT placenta previa, increases with an increasing number of caesarean sections D. treatment of uterine atony with prostaglandins is rarely assosciated with maternal adverse effects E. intravenous magnesium may facilitate replacement of an inverted uterus |
ANSWER E
A: FALSE: The classic presentation of AFE is characterized by sudden cardiovascular collapse, with profound systemic hypotension, cardiac dysrhythmia, cyanosis, dyspnea or respiratory arrest, pulmonary edema or the adult respiratory distress syndrome, altered mental status, and hemorrhage. B. FALSE 30% of patients with IUFD from abruption will have DIC. ( C. FALSE: Prior cesarean delivery increases the likelihood of placenta previa. Miller and associates (1996) cited a threefold increase of previa in women with prior cesarean delivery in over 150,000 deliveries at Los Angeles County Women's Hospital. The incidence increased with the number of previous cesarean deliveries; it was 1.9 percent with two prior cesarean deliveries and 4.1 percent with three or more. D. FALSE: PGF2alpha has significant side effects. PGE2 (misoprostil) has fewer side effects. E. TRUE: "Uterine relaxation may be necessary to replace the uterus; β-sympathomimetic agents, magnesium, and nitroglycerin all have been used to achieve this goal." (Miller 7th ed Ch 69) |
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ANZCA Version [Jul07]
In relation to obstetric haemorrhage A. amniotic fluid embolism is unlikely to present as unexplained haemorrhage B. cell salvage is too dangerous to be recommended because of potential contaminants C. coagulopathy after severe placental abruption is ONLY likely if fetal death in-utero occurs D. intravenous magnesium may facilitate replacement of an inverted uterus E. placenta percreta can be excluded by ultrasound examination |
ANSWER D
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SG60 ANZCA version [Jul07]
Pneumoperitoneum for laparoscopy is commonly associated with an INCREASE in each of the following EXCEPT A. arterial pressure B. inotropic state C. secretion of vasopressin D. systemic vascular resistance E. venous resistance |
ANSWER B
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SF85 ANZCA Version [Jul07]
Regarding non-obstetric abdominal laparoscopic surgery during the second trimester of pregnancy A. carbon dioxide pneumoperitoneum induces foetal acidosis B. fetal heart rate is depressed if maternal intra-abdominal pressure reaches 12 mmHg C. mechanical ventilation during general anaesthesia should be used to maintain a maternal arterial PaCO2 of 40 mmHg D. premature labour is a common complication unless prophylactic tocolytics are used E. the risk of miscarriage or premature labour is NOT increased |
ANSWER A
# A - TRUE - "a trend toward increasing fetal acidosis during a 90- to 120-minute exposure to a CO2 pneumoperitoneum" # B - FALSE intraabdo pressures were kept 12-15 in most cases, and no fetal bradycardia # C - False - Should aim lower (eg 32mmHg) (Yao and Artusio) # D - ?? - Probably not best answer; seems quite common if the patient has appendicitis (Y and ) but prophylactic tocolytics are debated # E - False - Clearly increased risk of spontaneous abortion in 1st and 2nd trimester |
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AZ02 ANZCA Version [Jul07]
A healthy female patient is undergoing a laparoscopic sterilisation under a relaxant based general anaesthetic. Which of the following monitors does NOT have to be in continuous use? A. Capnograph B. Electrocardiogram C. Oximeter D. Oxygen analyser E. Ventilator disconnect alarm |
ANSWER B
As per ANZCA document PS18: * ECG: correct "must be available for every anaesthetised patient" * Pulse oximeter "A pulse oximeter must be in use for every anesthesied patient" * Breathing system disconnection or ventilation failure alarm: "must be in continuous operation" * Oxygen analyser: "must be in continuous operation for every patient when an anaesthesia delivery system is used" * Carbon dioxide monitor: "must be in use for every patient under GA" |
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SF 38yo obese female with DM, other comorbidities, undergoing LSCS with spinal anaesthetic with a 27G whitacre needle, having this and that, blah, blah. then two days later complains of numbness on a small patch on lateral aspect of mid-thigh. On full neuro exam - no other signs/symptoms.
A. conus medullaris injury B. L2 nerve root compression C. L3 root lesion D. L4 root lesion E. meralgia paraesthetica |
ANSWER E
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SG63 ANZCA version [Apr08] Q118
Each of the following statements regarding the haemodynamic changes during pneumoperitoneum for laparoscopy is true EXCEPT: A. in patients with severe cardiac disease changes are qualitatively similar to those in normal patients B. right atrial pressure is NOT a reliable indicator of cardiac filling C. they are well tolerated by morbidly obese patients D. they are well tolerated in cardiac transplant patients with good ventricular function E. they are well tolerated in patients with low cardiac output secondary to low preload |
ANSWER E
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[Apr08]
At what level of intra-abdominal does cardiac output fall? A. 10 mmHg B. 20 mmHg C. 30 mmHg D. 40 mmHg E. 50 mmHg |
ANSWER C
At IAP of approximately 30mmHg, CVP falls significantly from previous levels but remains high in comparison with preinsufflation levels. Trendelenburg's position may not overcome the decreases in VR and CO presumably because of pressure on the inferior vena cava. Cardiac index falls to 50% of preoperative values in 5 min |
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SG65 ANZCA version [Apr08] Q108
Prolonged Trendelenburg (head-down) positioning causes: A. no change in intracranial pressure B. no change in intraocular pressure C. no change in pulmonary venous pressure D. increased myocardial work E. increased pulmonary compliance |
ANSWER D
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SF (Q105 August 2008) A 25yo primipara with an uncomplicated pregnancy presents to delivery suite in labour at term. Her membranes spontaneously rupture soon after, and it is blood-stained. At the same time, a severe foetal bradycardia appears on the CTG. What is the most likely cause of this?
A. Placenta accreta B. Placental abruption C. Uterine rupture D. Vasa praevia E. True knot in the umbilical cord |
ANSWER D
asa praevia (vasa previa AE) is an obstetric complication defined as "fetal vessels crossing or running in close proximity to the inner cervical os. These vessels course within the membranes (unsupported by the umbilical cord or placental tissue) and are at risk of rupture when the supporting membranes rupture. These vessels may be torn at the time of labor, delivery or when the membranes rupture. It has a high fetal mortality because of the bleeding that follows. [2] The bblood lost is foetal not maternal blood hence the high mortality. The classic triad are membrane rupture followed immediately by painless vaginal bleeding and fetal bradycardia. |
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SF (Q141 Aug 2008) Patient with placenta acreta. Surgical management MOST likely to save her life
A B lynch suture around the uterus for external tamponade B Rusch balloon in the uterus for internal tamponade C ligation of the internal iliac arteries D ligation of the uterine arteries E subtotal or total hysterectomy |
ANSWER E
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SF4. Hypertensive female at 38 weeks gestation BP 180/110. CTG shows no foetal distress. First Hb 110 and second is 109. First plt count 90 then drops to 40. AST increases from 50 to ? 120. Most appropriate management is
a. deliver the baby b. various antihypertensive medication options c. 20mg frusemide d.? e.? |
ANSWER B
Control BP first then deliver baby. No foetal distress. Delivery is definitve treatment but stabilising patient imperative. Drugs of choice :Antihypertensive drugs that can be safely used include labetalol, nifedipine and hydralazine. The choice should be made on clinician familiarity and experience with a particular agent. |
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You are called for a labour epidural. The woman is extremely distressed and in the middle of your consent process states “Just take my pain away” . You:
A. Place epidural then when calmed return to advise her of risks and complications B. Explain she has to hear all the potential complications and refuse to place epidural without consent C. Take consent from partner D. Perform spinal to relieve pain, then consent her for epidural E. Go away and return when she is more cooperative |
ANSWER B
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You are on call for a maternity hospital. Your junior registrar calls you after having inserted a labour epidural in an extremely anxious 19 yo parturient, and obtained blood in the catheter. He informs you the epidural space was found by LOR at 6cm and the catheter has been inserted to 12 cm. Your first instruction should be:
A. Flush with saline then check again for blood (NOT an option - option was just flush with saline and secure and use) B. Aspirate again for blood C. Give 3mls 2% lidnocaine with 1:200 000 adrenaline D. Pull back 2cm and check again for blood E. Remove epidural and start again |
ANSWER D
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Pre-eclamptic woman BP 180/110. Aim to drop BP to
a) 150-160 b) 140-150 c) 120-130 d) 110-120 e) 100-110 |
ANSWER B
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Highest likelihood of motor block with labour epidural analgesia:
A)Nurse initiated epidural topups B)Anaesthetist initiated epidural topups C)PCEA D)Continuous epidural infusion E)All associated with same motor block |
ANSWER D
ANZCA pain book page 189: comparison with continuous epidural (vs PCEA) first study quoted found higher incidence motor block with continuous (but also better pain scores) |
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Emergency caesarean section for foetal distress (and foetal acidosis on scalp probe?). what is best option to raise gastric pH preop:
A)Oral Na Citrate B)Ranitidine IV C)Ranitidine oral D)Omeprazole IV E)Omeprazole oral F)Metoclopramide 20 IV |
ANSWER A
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Trauma pregnant patient (?32wks) BP 70/40, P 50, intubated in emergency department, next management step:
A)L tilt pelvis B)IV fluid bolus C)Arrange urgent caesarean section D)Vasopressor options (?Adrenaline, Metaraminol) A. Basics first, then fluid, then pressor. |
ANSWER A
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21. (NEW) Maternal collapse post-delivery. What is NOT consistent with Amniotic fluid embolism?
a. Seizure b. Petechial rash c. Hypotension d. Coagulopathy e. Cardiac arrest |
ANSWER B
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43. A woman is being treated for pre-eclampsi. She is given 10 grams Magnesium sulphate in 1 h, instead of 1 gr per 1 h, Mg level 5-6, and patient is hyporeflexia. The best treatment is:
a. calcium b. IV fluid c. Furosemide d. ? |
ANSWER ??A
Was there and option of waiting to repeat the level a few hours later? |
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SF86 Most common cause of maternal cardiac arrest
A. PE B. AFE C. Haemorrhage D. Preeclampsia E. cardiomyopathy |
ANSWER B
ANZCA blue book 2009 Maternal morbidity and mortality, Table 1 p 17. Major causes of cardiac arrest during pregnancy: VTE, AFE, haemorrhage, HTN, sepsis, trauma, cardiac disease, iatrogenic. |
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SF89 Most likely change on CTG with anaesthesia for non-obstetric surgery at 32 wks
A. Loss of beat to beat variability B. No change C. Late decels D. Variable Deccels E. uterine contractions |
ANSWER A
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40.Pregnant woman presents with narrow complex tachycardia HR 190, stable BP 100/60. No response to vagal manoevures. Management?
A. adenosine 6mg B. DCR C. amiodarone D. Atenolol E. ? |
ANSWER A
ARC Guideline 11.11 - Managing Acute Dysrhythmias says that in a patient with no "adverse features" start with vagal manoeuvres. If that does not work next step is adenosine 6mg, then 12mg if required. Next step is Ca2+-channel blocker (verapamil or diltiazem). The fact that she is pregnant is not irrelevant from the treatment point of view, but main priority is the life of the mother. Consideration of effects of drugs on fetus is important, but there is no point witholding the correct treatment because of potential effects on fetus if the mother dies as a result of witholding the drug anyway. |
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SF87 [Mar10] [Aug10] Labour epidurals increase maternal and foetal temperature. This results in neonatal
A. Increased sepsis B. Increased investigations for sepsis C. increased non shivering thermogenesis D. Increased need for resuscitation E. Cerebral palsy |
ANSWER B
Labour epidural analgesia is associated with an increase in maternal core body temperature, but also with an increased neonatal temperature and fetal heart rate. Several studies have shown that labour epidural analgesia is associated with increased neonatal neonatal sepsis evaluations, but no increase in neonatal sepsis. |
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SF88 [Mar10] [Aug10] Maternal cardiac arrest. In making the diagnosis of amniotic fluid embolism, large amount of PMNs surrounding foetal squamous cells are
A. Pathonomonic B. Supportive C. Only found at postmortem D. Irrelevant E. Incidental |
ANSWER B
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53.25 yo primip ?38/40 gestation with beta thalassemia trait for epidural. BP 140/95, mild proteinuria ...something else... Best test before you will put in epidural
A. Coagulation screen B. Hb C. Platelet count D. skin bleeding time E. |
ANSWER C
* Thalassemia trait is a red-herring. No effect on clotting/epidural placement. Money is on pre-eclampsia Main thing to look at is the platelet count. Answer is C. * See Oxford Handbook 2nd edn - p.744. - If plt>100, proceed. - If plt<100, do coags. - If plt 80-100, and coags normal - regional is OK. |
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54.Another pregnant lady ?39/40 with BP185/115 , 4+proteinuria, clonus. IDC placed, 10mLs of dark coloured urine only for the last few hours. Initial management
A. 500mL Crystalloid bolus B. IV hydralazine C. IV Magnesium D. insert epidural |
ANSWER B
* By definition she has SEVERE pre-eclampsia. * A - False. Although they are usually intravascularly deplete, IV fluids should be given cautiously as these women are prone to develop pulmonary oedema. Volume expansion alone can reduce SVR and systolic BP. Oliguria should be treated with careful IV fluid challenge. The BJA CEACCP article (see below) states that a bolus of 250ml crystalloid should be given, but if no improvement (in urine output) a CVC should be inserted before any further fluid given. Then be guided by CVP and urine output. Crystalloid decreases plasma oncotic pressure, while colloids increase it and have a greater tendency to cause pulmonary oedema. However, if CVP low, can use colloid. I say false because 500ml is probably a bit too large as a bolus initially. * B - TRUE. Initial management should aim to reduce the BP. This is the best of the options, although the CEACCP article also states that careful volume expansion should precede the use of vasodilators, so as not to drop the BP too much. That is not one of the options though, and I think this is the best option. * C - False. Initial attempts to reduce BP and improve urine output should probably precede Mg administration. Anyway, giving someone with minimal urine output a large bolus of IV Mg increases the chances of Mg toxicity. Should give IV fluids before giving Mg. * D - False. Epidurals are desirable in pre-eclampsia but in severe pre-eclampsia you should try and reduce the BP first, and always check the platelet count +/- coags BEFORE placing epidural. |
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TMP-Jul10-001 Pre-eclamptic woman, BP 170/110, headache, proteinuria 1.2g. Which of the following NOT to use for control of her hypertension:
A. Magnesium B. SNP C. GTN D. Hydralazine E. Metoprolol |
ANSWER A
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TMP-Jul10-048 Amniotic fluid embolism. Cause of death in first half hour ?
A. Pulmonary hypertension B. Malignant arrhythmia C. Pulmonary oedema D. Hypovolaemic shock E. |
ANSWER A
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TMP-Jul10-061 Severe pre-eclampsia. WORST treatment option:
A. Magnesium B. Nifedipine C. Metoprolol D. SNP E. |
ANSWER A
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TMP-Jul10-062 In pregnancy the dural sac ends at:
A. T12 B. L2 C. L4 D. S2 E. S4 |
ANSWER B
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16. Magnesium for treatment of pre-eclampsia. What is the therapeutic level? (I think this may be a repeat of an old question, but i remember two of the options were-
A: B: 3 - 5 C: 5 - 7 D: E: |
???
THerapeutic range 1.7-3.5 mmol/L |
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SF01
Best immediate treatment of severe post-partum haemorrhage after delivery of a complete placenta: A. IV Ergometrine B. Blood transfusion C. Evacuation of uterus without blood transfusion D. Bimanual compression of the uterus E. Aortic compression |
ANSWER A
This is the simplest and least invasive step of the five options outlined. Williams states that the "fundus should always be palpated following placental delivery to make certain that the uterus is well contracted. If it is not firm, vigorous fundal massage is indicated. Most often, 20 U of oxytocin in 1000 mL of lactated Ringer or normal saline proves effective when administered intravenously at approximately 10 mL/min (200 mU of oxytocin per minute) simultaneously with effective uterine massage." (Williams Obstetrics Ch 35). Given that it is standard practice in Australia to administer oxytocin after the 2nd stage of labour (i.e. after the patient is fully dilated and the baby is delivered), the next step is uterine massage and ergometrine iv. |
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SF07 [1987] [Aug92]
Uterine relaxation might be required in: A. Breech delivery B. Manual removal of placenta C. Transverse lie for caesarian section D. Assisted delivery for breech |
ALL TRUE
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SF08 [1989]
A woman already in the lateral tilt position for LSCS with epidural in situ, develops profound hypotension. The immediate treatment is: A. IV crystalloids B. IV Ephedrine C. IM Methoxamine D. IV colloid E. Trendelenburg |
ANSWER A and B
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SF09 [Jul97] [Apr98] (type A)
In relation to foetal outcome, which of the following is most important: A. Induction-delivery time B. Displacement of the uterus C. Minimal Thiopentone on induction D. The use of 100% oxygen E. Keeping inhalational agent use to a minimum |
ANSWER B
Uterine incision to delivery (U-D) time is more important than induction to delivery (I-D) time. A U-D >3mins is assoc with lower umbilical pH. Regional: prolonged I-D doesn't adversely affect Apgars provided hypotension is treated. GA: prolonged I-D >8mins may worsen neonatal acidosis, but not if hypotension is treated, and maternal FIO2at least 65%. Prolonged exposure to volatile/N2O may decrease 1min apgar, but not 5min. |
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SF11 ANZCA version [2001-Apr] Q61, [2004-Apr] Q102, [2005-Apr] Q91, (Similar question reported in [1988] [Aug95] [Apr97] [Jul97] [Apr98] [Apr99])
Factors which do NOT contribute to the increased risk of aspiration pneumonitis during pregnancy include A. increased gastrin production B. a tendency for the stomach to be pushed up against the left diaphragm C. increased acidity of gastric secretion D. increased volume of gastric secretion E. decreased secretion of the hormone motilin |
ANSWER A
# A. increased gastrin production - true; "We confirmed that pregnant women have much greater and more acidic gastric contents than the nonpregnant patients preoperatively, and it is not because of serum gastrin concentration" (J Clin Anesth. 2005 Sep;17(6):451-5.) [this was after the question was posed obviously] # B. a tendency for the stomach to be pushed up against the left diaphragm - maybe false; the gravid uterus causing raised intraabdominal pressure is traditionally a factor contributing to aspiration risk # C. increased acidity of gastric secretion False, see A # D. increased volume of gastric secretion False, see A # E. decreased secretion of the hormone motilin Apparently this is false; * "Plasma motilin concentrations were measured in 37 women during the second and third trimester of pregnancy and one week after delivery. The mean plasma motilin concentrations, both fasting and after a glucose load and a mixed meal, were significantly (p less than 0.001) reduced during pregnancy, returning to the normal range one week post partum. Pregnancy appears to have a profound inhibitory effect on plasma motilin, and this may in part be responsible for the gastrointestinal hypomotility associated with pregnancy |
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SF11 ANZCA version [Sep05] Q89
Factors which contribute to the increased risk of aspiration pneumonitis during pregnancy include all the following EXCEPT A. a tendency for the stomach to be pushed up against the left diaphragm B. decreased secretion of the hormone motilin C. increased acidity of gastric secretion D. increased gastrin production E. increased volume of gastric secretion |
ANSWER D
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SF13 [1988] [Mar94]
Uterine tone decreased / increased by: A. Serotonin B. Prostaglandin E2 C. Ketamine D. Verapamil E. Magnesium F. Beta-2 agonists G. GTN |
Uterine tone increased with
* Prostaglandin E2 * Ketamine * Serotonin Uterine tone decreased with * verapramil * magnesium * Beta 2 agonist * GTN |
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SF15
Contraindications to the use of Ergometrine: A. Vasopressors B. Pre-eclampsia C. Current use of Oxytocics D. Halothane |
ANSWER B
Ergometrine is contraindicated: * in patients who have previously displayed hypersensitivity or idiosyncratic reactions to ergometrine, other ergot alkaloids or any of the ingredients in the Ergometrine Injection preparation * for the induction of labour and during the first and second stages of labour * if there is any suspicion of retained placenta * in eclampsia or preeclampsia, and in cases of threatened spontaneous abortion. * in severe or persistent sepsis * in patients with peripheral vascular disease or heart disease and in patients with hypertension or a history of hypertension * where impaired hepatic or renal function exists |
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SF16 [1987] [1988] [Mar93] [Aug93] [Apr97]
Syntocinon 10U given IV as a bolus after delivery causes: 1. Tachycardia 2. Vomiting 3. Hypotension 4. Fitting secondary to water retention 5. Bradycardia 6. Arrhythmias |
Syntocinon 10U given IV as a bolus after delivery causes:
* 1. Tachycardia - true; reflex baroreceptor mediated * 2. Vomiting - true; secondary to hypotension commonly * 3. Hypotension - most true; probably the most common adverse effect of an oxytocin bolus * 4. Fitting secondary to water retention - less true; would be very uncommon * 5. Bradycardia - less true; commonly tachycardia occurs * 6. Arrhythmias - less true |
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SF18 [1988] [Mar91]
Drugs (? NOT) readily crossing placenta: A. Atropine B. Chlorpromazine C. Naloxone D. Diazepam E. Lignocaine F. Suxamethonium |
ANSWER F
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SF18b [Aug92]
Which of the following drugs does NOT significantly cross the placenta? A. Heparin B. Warfarin C. Propranolol D. Cimetidine |
ANSWER A
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SF22 ANZCA version [2003-Apr] Q116
The commonest cause of maternal convulsions in the immediate post-partum period is A. amniotic fluid embolism B. eclampsia C. epilepsy D. local anaesthetic toxicity E. water intoxication due to syntocinon infusion |
ANSWER B
"The most common cause of postpartum seizures is eclampsia." p.208 Handbook of Obstetric and Gynecologic Emergencies,3e Benrubi 2005, Differential diagnoses for postpartum seizure following epidural analgesia: * Eclampsia * Epilepsy * Drug/alcohol withdrawl * Meningoencephalitis * Subarachnoid haemorrhage * Space occupying lesion * Cortical vein thrombosis * Metabolic disturbances * Migraine * Idiopathic * Post dural puncture headache * Pneumocephalus |
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SF23b [Jul97] [Apr98]
Fully dilated primipara for breech delivery. Increased risk of (type K) 1. Postpartum haemorrhage 2. Cervical tear 3. Perineal laceration 4. Retained placenta |
ALL TRUE
* Breech presentations: 3.5% of all pregnancies * result in increased maternal morbidity * greater likelihood of: o cervical lacerations o perineal injury o retained placenta o maternal haemorrhage o neonatal morbidity and mortality o cord prolapse |
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SF23 [Jul98] (type K)
Which of the following are TRUE of a frank breech presentation? There is an increase in: A. Post partum haemorrhage B. Intrapartum haemorrhage C. Cervical laceration D. Placental retention |
ALL TRUE
* Breech presentations: 3.5% of all pregnancies * result in increased maternal morbidity * greater likelihood of: o cervical lacerations o perineal injury o retained placenta o maternal haemorrhage o neonatal morbidity and mortality o cord prolapse |
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SF27 ANZCA version [Sep90] [Mar91] [Mar93] [Aug93] [2003-Apr] Q48, [2003-Aug] Q83
The pain of the first stage of labour is transmitted by: A. Grey rami communicantes B. T10-L1 anterior roots C. The hypogastric plexus D. Inhibitory nerves to the internal vesical sphincter E. Parasympathetic nerves |
ANSWER C
Neural pathway of pain * The uterus and cervix are supplied by afferents accompanying sympathetic nerves in the uterine and cervical plexuses, the inferior, middle and superior hypogastric plexuses and the aortic plexus. * The small unmyelinated 'C' visceral fibres transmit nociception through lumbar and lower thoracic sympathetic chains to the posterior nerve roots of the 10th, 11th and 12th thoracic and also to 1st lumbar nerves to synapse in the dorsal horn. * The chemical mediators involved are bradykinin, leukotrienes, prostaglandins, serotonin, substance P and lactic acid. * As the labour progresses severe pain is referred to the dermatomes supplied by T10 and L1. * In the second stage: the direct pressure by the presenting part on the lumbosacral plexus causes neuropathic pain. Stretching of the vagina and perineum results in stimulation of the pudendal nerve (S2,3,4) via fine, myelinated, rapidly transmitting 'A delta' fibres3. From these areas, the impulses pass to dorsal horn cells and finally to the brain via the spino-thalamic tract. |
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SF28 ANZCA version [Mar91] [2001-Aug] Q133, [2002-Mar] Q123
Partial lateral tilt during a caesarean delivery at term 1. on average results in improved fetal oxygenation 2. on average results in improved maternal oxygenation 3. is more effective in combating supine hypotension when it is to the left than to the right 4. is effective in combating supine hypotension in all patients when it is 15 degrees in magnitude |
ANSWER 1 and 1. True. Late decelerations as a sign of foetal hypoxia are 5x more common in the supine position.
2. False. My extremely detailed review article doesn't mention it anyway. No clear reason exists for maternal hypoxia. 3. True. Left tilt is generally better than right. There is an occasional case where right tipping is better, thought to be due to a left-leaning uterus. 4. Untrue. In some tilt of up to 40 degrees is needed and manual uterine displacement is sometimes used. |
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SF29d ANZCA version [2004-Aug] Q124, [2005-Apr] Q37
The target serum magnesium level in a patient with pre-eclampsia receiving a magnesium infusion is A. 1-2 mmol/l B. 2-3.5 mmol/l C. 3-6 mmol/l D. 4-6 mmol/l E. 5-8 mmol/l |
ANSWER B
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SF29e ANZCA version [2005-Sep] Q76
When magnesium sulphate is used in the treatment of preeclampsia A. its tocolytic action commonly delays the progress of labour B. it potentiates neuromuscular blockade by depolarising muscle relaxants C. therapeutic blood levels are 6 - 8 mmol.l-1 D. when given as an infusion it frequently produces hypotension E. none of the above |
ANSWER B
A. FALSE: In term nulliparous women, neither preeclampsia nor magnesium prophylaxis affected labor duration. B. TRUE C. FALSE 2-3.5mmol/L D. TRUISH E. FALSE |
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SF29b [Mar91]
Magnesium for pre-eclampsia by IV infusion: A. Lengthens QT B. Produces hypotension C. Prolongs labour D. Prolongs AV conduction E. Side effects include AV bradycardia |
ANSWER D
* A True edit disagree. if it did would you use it for Torsades? Magnesium has no effect on QT intervals. * B ?True - can → hypotension. * C False * D True * E ?True |
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SF34 [Aug92] [Mar93] [Aug96]
The epidural dose of local anaesthetic that is required to produce the same mean height of block in a pregnant woman at term, when compared with a non-pregnant woman of the same age requires on average: A. 30% more B. 15% more C. The same D. 15% less E. 30% less |
ANSWER E
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SF35 [Mar93] [Apr96]
Recognised effects of aspirin 100mg taken daily until term by patients with at risk of developing pregnancy-induced hypertension include: A. Increased platelet aggregation B. Decreased thromboxane A2 synthesis C. Decreased prostacyclin synthesis D. Increased blood loss at delivery E. Premature closure of the foetal ductus arteriosus |
ANSWER B
Compared to women with normal pregnancies, women with preeclampsia have a relative excess of thromboxane A2 (a platelet-derived vasoconstrictor and platelet aggregation promoter) compared to prostacyclin (an endothelial cell-derived vasodilator and platelet aggregation inhibitor).9–11 The correction of the thromboxane A2 to prostacyclin ratio caused by aspirin may help prevent the development of preeclampsia and its complications. |
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SF36 [Mar93]
In pregnant patients with severe chronic respiratory disease A. The presence of cor pulmonale is associated with a maternal mortality of more than 70% B. Asthma typically gets worse C. There is usually a similar change in the severity of asthma with each pregnancy D. Chronic maternal hypoxia is poorly tolerated by the foetus |
ANSWER C
Asthma (Adelaide ICU notes) a. incidence ~ 1:20 persons ~ 1% of pregnant women ~ 10-15% of these will require hospitalisation ~ 50% will have no change in their asthma with pregnancy ~ 25% will improve & 25% worsen b. conditions associated with maternal asthma preterm delivery, low birthweight infants & perinatal death occur more frequently haemorrhage, PIH, requirement for induced labour also more common c. factors which affect asthma in pregnancy reduction in FRC ~ 20%, increased MRO2, increased progesterone - increased RR & MV |
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SF43 ANZCA version [2002-Mar] Q110, [2002-Aug] Q138 (Similar question reported in [Aug96] [Apr97] [Jul97])
A pregnant 30-year-old woman is given nitrous oxide and oxygen for late first stage and second stage analgesia. Induction of analgesia is rapid because 1. functional residual capacity (FRC) is reduced 2. the cardiac output is increased in pregnancy 3. alveolar wash-in of agent is rapid due to hyperventilation 4. hyperventilation increases uterine blood flow |
ANSWER 1 and 3
FRC is reduced and hyperventilation causes rapid wash-in of agent. Increased cardiac output would slow onset of analgesia due to N2O and uterine blood flow is irrelevant as N2O exerts a CNS effect to cause analgesia. |
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SF44 ANZCA version [2003-Aug] Q48 (Similar question reported in [Aug96] [Apr97] [Jul97])
A 35 year old primipara at 38 weeks gestation is admitted to hospital with abruptio placentae. The fetal heart rate is 100 beats per minute, and the cervix is unfavourable. Caesarean section is planned. The anaesthetic of choice is A. thiopentone, succinylcholine, isoflurane and oxygen B. spinal anaesthesia C. thiopentone, nitrous oxide, isoflurane and oxygen D. thiopentone, succinylcholine, nitrous oxide and oxygen E. epidural anaesthesia |
ANSWER A
Abruption associated with risk of DIC. GA: Thio, sux, iso, oxygen. FUrthermore A heart rate of 100 is nonreassuring, and placental abruption associated with siginificant bleeding, and coagulopathy, agree GA, thio sux iso oxygen ( avoid N20 as increase risk of gas embolus/ amniotic fluid embolus and fetus is compromised and will need supplemental oxygen) The indications for GA are * Speed * Coagulopathy * Anticipated bleeding - such as anterior pl. praevia in multip * Sepsis (relative) * Tethered cord * Failed regional * Patient refuses regional |
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SF49 [Mar00]
Patient has epidural anaesthesia for manual removal of placenta, surgeon requests uterine relaxation, you would (type A) A. Increase concentration of inhalational agents B. Use 50-100 micrograms of GTN C. ? |
ANSWER B??
Uterine relaxation choice depends on stability. If stable: 50mcg GTN IV, S/L GTN. If a little underfilled: MgSO4, salbutamol bolus. If they're struggling: GA with volatile. |
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SF51 ANZCA version [Jul00] [2002-Mar] Q82
You are called to see a labouring 24 year old primigravida with preeclampsia. She is convulsing. Following initial management, the best drug to prevent further convulsions is A. phenytoin B. diazepam C. magnesium sulphate D. carbamazepine E. hydralazine |
ANSWER C
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SF56 ANZCA version [2002-Aug] Q109, [2003-Apr] Q75 [Mar06]
In preeclampsia A. once delivery of the placenta takes place, the condition improves B. in the absence of other risk factors a platelet count of greater than 50 is adequate for epidural anaesthesia C. corticosteroid therapy has no effect on the severity of thrombocytopenia D. magnesium sulphate halves the incidence of eclampsia E. spinal anaesthesia contraindicated |
ANSWER D
* A, truish... the condition usually/eventually improves... but not always * B, false... 70 seems to be the current line in the sand, but how low is really safe?? Obstetric Anaesthesia Scientific Evidence from ANZCA gives 75 as a safe figure. * C, having wasted far too much time in the literature, this is probably false (eg [1] (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15802415&itool=iconabstr&query_hl=9&itool=pubmed_docsum)), especially in HELLP [2] (http://bmj.bmjjournals.com/cgi/content/full/329/7460/270)... but it could be true [3] (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=14973983&itool=iconabstr&query_hl=9&itool=pubmed_docsum) * D, TRUE as abstract says: "Magnesium sulphate halves the risk of eclampsia, and probably reduces the risk of maternal death. There do not appear to be substantive harmful effects to mother or baby in the short term." From MAGPIE * E. false |
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SF57 ANZCA version [2003-Aug] Q143, [2004-Apr] Q66, [Mar06]
During elective caesarean section under spinal anaesthesia A. maternal hypotension requiring intervention is infrequent B. the duration that the maternal systolic blood pressure is below 100 mmHg is of less importance for producing adverse cord blood acid-base measures than the degree of fall in systolic blood pressure C. there is a significant difference between the use of rescue boluses compared to infused prophylactic ephedrine on the status of cord blood acid-base measures D. there is less nausea and vomiting if ephedrine is prophylactically infused compared to using it as a rescue bolus to treat any maternal hypotension when it does occur E. there is no adverse effect from maternal hypotension on cord blood acid-base values |
ANSWER D
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SF61 ANZCA version [2004-Apr] Q144, [2005-Sep] Q88
The optimal patient position for anaesthetising a woman at term with an umbilical cord presenting externally is A. knee-chest (i.e. on hands and knees) B. left lateral (i.e. on side with left side down) C. supine with head down (and lateral tilt) D. supine with head elevated (and lateral tilt) E. supine and level (with lateral tilt) |
ANSWER B
Well the best way to deal with this is as follows: 1. Get obstetrician to calm down 2. Ask assistant to place hand on head of baby, and at the same time feel cord. 3. Ask assistant if cord is warm and pulsatile. 4. If cord is warm and pulsatile, take your time. You are safer placing the patient on their side, and performing a spinal. Don't listen to the howling obstetric staff, your priority is the safety of the mother at all times. You do no favours inducing GA and failing to get an airway, when there is time to perform a safer manouvre. 5. If cord is cold and non-pulsatile, I would then induce GA. The safest method for mother is lateral tilt and horizontal. Some people advocate head down to relieve pressure on the cord, but this decreases FRC and endangers the mother. I think there is no great sense in this if an assistant is pushing the head back already. |
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SF64 ANZCA version [2005-Apr] Q102
In women with congenital heart disease the clinical scenario associated with the greatest maternal mortality is A. aortic stenosis with a valve area less than 0.7 cm2 B. Eisenmenger's syndrome C. left ventricular ejection fraction less than 35% D. Marfan's syndrome with dilated aortic root E. significant aortic coarctation |
ANSWER B
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SF70 ANZCA version [2003-Apr] Q115
The most important characteristic of non-particulate antacids in obstetrics is their A. inability to cross the placenta B. low cost C. pleasant taste D. reduced incidence of nausea E. speed of onset of action |
ANSWER E
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SF75 ANZCA version [2003-Aug] Q23
Oxytocin, when administered intravenously in a bolus dose of 10 units immediately postpartum A. has a half life of approximately 30 minutes B. commonly induces vomiting C. commonly causes premature atrial contractions D. often lowers blood pressure E. causes transient bradycardia |
ANSWER D
* A. has a half life of approximately 30 minutes----FALSE "The relative ease with which the rate and force of uterine contractions can be regulated by the intravenous infusion of Syntocinon is due to the short half-life of oxytocin. Values reported by various investigators range from 3 to 20 minutes." (Mims online) * B. commonly induces vomiting----Is a SE, but occuring commonly? * C. commonly causes premature atrial contractions-----Can do, but commonly? * D. often lowers blood pressure---- TRUE---Best answer "Another pharmacological effect observed with high doses of oxytocin, particularly when administered by rapid intravenous bolus injection, is a transient direct relaxing effect on vascular smooth muscle, resulting in brief hypotension, flushing and reflex tachycardia" (Mims online) * E. causes transient bradycardia----Possible. It causes Fetal bradycardia. |
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SF76 ANZCA version [2004-Apr] Q140
Concerning backache in obstetrics A. gestational backache occurs in 10-20% of pregnant women B. posterior pelvic pain is much more common than lumbar pain during pregnancy C. relaxin production is decreased during pregnancy D. risk factors include smoking history and ethnicity E. the principal diagnostic tool is magnetic resonance imaging (MRI) |
ANSWER B and D
This question appears to come from Curr Opin Anaesthesiol. 2003 Jun;16(3):269-73 * A - incidence 40-90% * B - The locations of backache can be thoracic or the low back. The pain occurring in the low back can further be classified into lumbar pain (LP) and posterior pelvic pain (PPP). PPP is four times more common than LP during pregnancy [1]. * C - The etiology of GBP is multifactorial [1-3]. The most widely accepted explanations relate to the secretion of relaxin, a hormone that facilitates the loosening of the supporting structure, tendons, and ligaments, making the spine and sacroiliac joints (SIJs) ‘less stable’, and the expansion of the uterus causing pregnant women to shift their center of gravity resulting in back strain [1-3]. * D - The risk factors that contribute to the development of GBP are: a history of backache, ethnic background, smoking, parity, type of work, age, fetal weight, and rapid weight gain over a short period of time. Other pathological changes such as lumbosacral disc herniation, spondylolisthesis, coccydynia can also cause GBP [1-3]. * E - The evaluation of pregnancy-induced backache begins with an in-depth history and a thorough physical examination. Once a medical history has been completed, a physical examination, with emphasis on the back and a detailed neurological examination, should be performed. It is a relative contraindication to utilize radiographs as part of a backache work-up during early pregnancy. Magnetic resonance imaging is a safe means of assessing the spine and pelvis [2]. |
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SF84 [Apr07] Q112
Analgesic requirements during labour are reduced by each of the following except A. Acupressure B. Acupuncture C. Hypnosis D. One to one support by midwife E. TENS |
ANSWER A
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