CC OB and Peds Flashcards
In the US, the leading cause of maternal death associated with a live birth is:
A. Pregnancy induced HTN
B. PE
C. Cardiomegaly
D. Hemorrhage
Answer: B: PE at 21%, second is PIH
On a per kg basis, ventilatory parameters that remain unchanged from birth throughout adulthood include:
A. Deadspace
B. MV
C. FRC
D. CC
Answer: D
Also, Tidal volume
Well oxygenated fetal blood from the placenta has a PaO2 of approximately:
A. 40 mmHg
B. 60 mmHg
C. 80 mmHg
D. 100 mmHg
Answer: A
After delivery of a 4.0kg neonate, recurrent bradycardia is noted. An umbilical artery catheter is placed at which time the neonate becomes systolic. An appropriate dose of ephedrine would be:
A. 0.01 mg
B. 0.25 mg
C. 0.04 mg
D. 0.50 mg
Answer: C
Epinephrine 0.01 - 0.03
mg/kg is indicated for
neonatal bradycardia (< 60
bpm) and asystole. This is
usually delivered as a
1:10,000 solution.
A preterm (33 week gestation) neonate is delivered emergently by a C/S. The baby shows tachypnea, grunting, intercostal retractions and is cyanotic. The most likely cause of the cyanosis is
A. Insufficient surfactant production
B. Transposition of the great vessels
C. Insufficient HbgF production
D. Tetrology of Fallot
Answer: A
The most common cause of
respiratory distress in preterm
neonates is the respiratory
distress syndrome (RDS) also
known as hyaline membrane
disease. The syndrome is
responsible for 50 - 75% of
deaths in preterm neonates. It
is the result of deficient
production and secretion of
surfactant, which is produced
by type II pneumocytes.
Mature levels of surfactant
are not present until 35 weeks
of gestation.
Electrocardiographic changes associate with the third trimester of pregnancy include:
A. R axis deviation
B. First degree AV Block
C. Left axis deviation
D. Sinus Bradycardia
Answer: C
Elevation of the diaphragm
shifts the heart position in the
chest resulting in the
appearance of an enlarged
heart on a plain chest film and
in left axis deviation and T
wave changes on the
electrocardiogram.
You are asked to evaluate a 31 year old G3P2 woman in for a repeat C/S. Her PMH includes 2 previous C/s. She has been laboring for the previous 7 hours with little progress despite an oxytocin infusion. During the interview, she complains of sudden severe continuous abdominal pain radiating to her left shoulder. These symptoms are most consistent with:
A. Preeclampsia
B. Abrupto Placentae
C. Uterine Rupture
D. Placenta Previa
Answer C
Uterine rupture is often
heralded by severe abdominal
pain, referred to the shoulder
due to subdiaphragmatic
irritation by intra-abdominal
blood. Uterine rupture is
associated previous uterine
scars and excessive oxytocin
stimulation. Current
recommendations discourage
VBAC in women with two or
more previous uterine
incisions.
A 9 year old patient with a history of cerebral palsy is scheduled for release of contractures of the achilles tendons. The patient is receiving phenytoin for control of seizures. Anesthetic considerations for these patients include:
A. increased sensitivity to NDMR
B. Likelihood of GERD increased
C. possibility of severe hyperkalemia with use of succs
D. Avoidance of volatile anesthetics because of an increased incidence of MH in these patients
Answer: B
Management of anesthesia in
children with cerebral palsy
includes tracheal intubation
because of the propensity for
GERD and poor function of
laryngeal and pharyngeal
reflexes.
There is no increase
in the incidence of MH in
these patients and the use of
volatile anesthetics has been
shown to be safe.
Patients
receiving anticonvulsants may
be more resistant to the
effects of nondepolarizing
relaxants.
Despite the skeletal
muscle spasticity,
succinylcholine does not
produce abnormal potassium
release in these patients.
The most common morbidity encountered in obestetrics is:
A. Severe spesis
B. severe preeclampsis
C. HELLP syndrome
D. Severe hemorrhage
Answer: #1: Severe hemorrhage, #2: Severe preeclampsia
As compared to RA, the risk of maternal death from GA is approximately:
A. the same
B. three times higher
C. Eight times higher
D. 16x higher
Answer D
In the fetus, blood entering the RA from the IVC is preferentially directed to the:
A. Ductus Arteriosus
B. RV
C. Foramen Ovale
D. Ductus Venousus
Answer: C
Right atrial anatomy
preferentially directs blood
from the inferior vena cava
through the foramen ovale
into the left atrium.
Functional residual capacity is decreased in the neonate as a result of:
A. Increased lung compliance and decreased chest wall compliance
B. Decreased lung compliance and increased chest wall compliance
C. Increased lung compliance and increased chest wall compliance
D. Decreaed lung compliance and decreased chest wall compliance
answer: B
The small and limited number
of alveoli in neonates and
infants reduces lung
compliance; in contrast, their
cartilaginous rib cage makes
their chest wall very
compliant. The combination
of these two characteristics
promotes chest wall collapse
during inspiration and
relatively low residual lung
volumes at expiration.
Renal changes seen during pregnancy include a reduction:
A. Plasma levels of renin and aldosterone
B. The tubular threshold for glucose and amino acids
C. Glomerular filtration
D. Renal plasma flow
B
the tubular threshold for
glucose and amino acids.
Renal vasodilation increases
renal blood flow, glomerular
filtration and renal plasma
flow. Increased renin and
aldosterone levels promote
sodium retention. A decreased
renal tubular threshold for
glucose and amino acids is
common and often results in
mild glycosuria or
proteinuria.
Post-intubation laryngobracheobronchitis (croup) is most commonly seen in children of:
A. 0 - 1 years of age
B: 1 - 4 years of age
C: 4 - 7 years of age
D: 7 - 9 years of age
Answer: B
Post-intubation croup is due
to glottic or tracheal edema
and is associated with early
childhood (ages 1 - 4),
repeated intubation attempts,
large endotracheal tubes,
prolonged surgery, head and
neck procedures and
excessive movement of the
endotracheal tube. Nebulized
racemic epinephrine is an
effective treatment.
Of the following, the lowest degrees of placental drug transfer occurs with the use of:
A. Bupivacaine
B. Chloroprocaine
C. Lidocaine
D. Ropivacaine
Answer: B
Chloroprocaine has the least
placental transfer because it is
rapidly broken down by
plasma cholinesterase in the
maternal circulation.
The appropriate ETT diameter for a full term neonate is approximately:
A. 2.0 mm
B. 3.0 mm
C. 4.0 mm
D. 4.5 mm
Answer: B
For pediatric patients, the
appropriate diameter of the
endotracheal tube can be
estimated by the formula:
Tube diameter = 4 + (age/4)
Exceptions include premature
neonates (2.5 - 3.0 mm) and
full-term neonates (3.0 - 3.5
mm).
Pain during the latent phase of labor is usually confined to dermatomes:
A. T11-T12
B. L1 - L2
C. L3 - L4
D. L5 - S1
Answer: T11 - T12
Pain during the first stage of
labor is mostly visceral pain
resulting from uterine
contractions and cervical
dilatation. It is usually
initially confined to the T11 -
T12 dermatomes during the
latent phase, but eventually
involves the T1- - L1
dermatomes as the labor
enters the active phase.
A 12 year old patient is scheduled for an excision of a sellar craniopharyngioma. Suspected preoperative lab abnormalities in this patient include:
A. A decreased T4 level with an elevated thyrotropin level
B. An elevated plasma cortisol level
C. Hypernatremia
D. An elevated growth hormone
C
Craniopharyngioma is the
most common intracranial
tumor of nonglial origin in the
pediatric population. Because
the tumor can affect the
pituitary, endocrine
dysfunction is common.
Secondary hypothyroidism,
growth hormone deficiency,
secondary hypocortisolism
and diabetes insipidus should
all be suspected. Diabetes
insipidus can present
preoperatively as
hypernatremia, but may also
be seen 4 - 6 hours
postoperatively, due to
surgical damage to the
pituitary.
As compared to the non-pregnant patient, the incidence of pulmonary aspiration of gastric contents in the OB pt is
A. Approximately equal if cricoid pressure is applied
B. Twice as great
C. 4 to 5x greater
D. 8 - 10 x greater
Answer: C
4-5x greater
Pulmonary aspiration of
gastric contents is 4 - 5 times
greater in the obstetric patient
with an incidence of 1:400 -
500 as compared to an
incidence of 1:2000 in the
non-pregnant patient.
At 20 weeks gestation, frequently found changes in Heart sounds include:
A. loss of split of the first heart sound
B. Grade I or II diastolic murmur
C. Presence of a third heart sound
D. All of the above
Answer: C
Presence of third heart sound
Several changes in heart
sounds occur during
pregnancy. Early closure of
the mitral valve may cause a
split first heart sound. A third
heart sound can be heard in
most women by 20 weeks’
gestation. A benign grade I or
II systolic murmur is also
common. Diastolic murmurs
are pathologic.
A 24 year old patient presents to the ER in labor with contractions occurring every 4 minutes. She is at 32 weeks. Pharmacologic inhibition of uterine contractions is accomplished with:
A. IV Calcium chloride therapy
B. IV Betamethasone therapy
C. IV Metoprolol therapy
D. IV Ritodrine Therapy
Answer: D
The most commonly used
tocolytics are β2-agonists
(ritodrine or terbutaline) and
magnesium. Although
betamethasone may be given
to induce fetal production of
surfactant, it is not effective
as a tocolytic agent. More
recently, oxytocin antagonist,
atosiban, has show
effectiveness in patients of
greater than 28 weeks
gestation.
The position of the larynx in a Neonate is:
A. C2
B. C4
C. C6
D. C8
Answer: C4 (B)
Neonates and infants have a
proportionately larger head
and tongue, narrow nasal
passages, an anterior and
cephalad larynx (at vertebral
level C4 versus C6 in adults),
a long epiglottis and a short
trachea.
Clinically significant placental drug transfer has NOT been shown to occur with the use of:
A. Ephedrine
B. Labetalol
C. Glyco
D. Metoclopramide
Answer: C
A 38-postconception week neonate is scheduled for an emergent repair of an incarcerated inguinal hernia. The patient was delivered at 34 weeks of gestation. Anesthetic management of this patient should include:
A. Maintenance of Arterial PaO2 > 100 mmHg
B. Permissive Hypercapnia to reduce barotrauma to lungs
C. Maintenance of oxygen saturation between 89-94%
D. The use of 3% NaCl for fluid replacement
Answer: C
In this preterm neonate there
exists a substantial risk for the
development of retinopathy of
prematurity. Because the
optimal intraoperative oxygen
saturation for these infants is
not known, it is prudent to
limit oxygen supplementation
during the period of retinal
vascularization (up to 44
weeks postconception).
Efforts should be made to
maintain PaO2 between 50 -
80 mmHg and PaCO2
between 35 - 45 mmHg. This
results in a pulse oximetry
target of 89 - 94%.
Morphine is infrequently used as an analgesic during labor because of at equianalgesic doses, it appears to cause:
A. A higher incidence of fetal seizures compared to fentanyl
B. A higher incidence of fetal respiratory depression as compared to fentanyl
C. A greater loss of fetal thermal regulation as compared to fentanyl
D. A higher incidence of fetal bronchospasm as compared to fentanyl
Answer: B
Morphine is seldom used for
maternal analgesia because in
equianalgesic doses it appears
to cause greater respiratory
depression in the fetus than
meperidine or fentanyl.
A 10 kg child is scheduled for a resection of a skin lesion of the right thigh. The anesthetic plan calls for an LMA. The appropriate size for this patient is:
A. 1
B. 2
C. 3
D. 4
LMA 2
Pulmonary Aspiration during induction of GA in the pregnant woman is more likely the result of:
A. the posterior displacement of the stomach by the uterus
B. Placental gastrin secretion
C. Increased intragastric pressure
D. Progesterone-induced increase in LES
B
Factors complicating the airway management of the patient with trisomy 21 include
A. Microglossia
B. Prognathia
C. Hypertoniciy of master muscles
D. Occipitoatlantoaxial instability
Answer: D
Trisomy 21 or Down
syndrome is the most
common human chromosomal
syndrome. Airway
management in these patients
can be difficult due to
macroglossia, micrognathia,
narrow hypopharynx and
muscular hypotonia. There is
also a risk of spinal cord
compression due to
occipitoatlantoaxial
instability.
Pathophysiologic events associated with preeclampsia:
A. production imbalance between prostacyclin and thromboxane A2
B. Intravascular volume expansion
C. Decreased vascular sensitivity to catecholamines
D. Thrombocytosis
Answer: A
Pregnancy-induced
hypertension (PIH)
encompasses a range of
disorders, including
gestational hypertension,
preeclampsia and eclampsia.
Three principal mechanisms
serve as the etiology of PIH.
These mechanisms are:
abnormal sensitivity of
vascular smooth muscle to
catecholamines, placental
vasculitis, and an imbalance
in the production of
vasoactive prostaglandins
(thromboxane A2 and
prostacyclin).
Treatment of cardiac toxicity secondary to unintentional intravascular bupivacaine should include:
A. Control of arrhythmias with IV lidocaine
B. Control of arrhythmias with IV verapamil
C. Avoidance of cardioversion
D. Administration of 20% lipid solution
answer: D
20% lipid solution
Cardiac toxicity from
bupivacaine may be difficult
to treat. Hyperventilation with
oxygen should be
immediately instituted.
Ventricular dysrhythmias may
need large and multiple doses
of electrical cardioversion,
epinephrine, vasopressin and
amiodarone. The use of
calcium channel blockers is
not recommended. The
administration of a 20% lipid
solution at an initial dose of 4
mL/kg has been found to
improve survival.
In children under 5 years of age, the narrowest point of the airway is the:
A. Rina GLottis
B. Thyroid cartilage
C. Cricoid cartilage
D. Hyoid cartilage
Answer: C
In the parturient, uterine hypertonic has been associated with the use of large induction doses of:
A. Thiopental
B. Propofol
C. Etomidate
D. Ketamine
Answer: Ketamine
Uterine hypertonus may occur
with ketamine at doses > 2
mg/kg.
A 12kg child is scheduled for repair of an inguinal hernia. The patient had respiratory infection 2 weeks ago but now has full resolution of symptoms. At this time, the patient is at increased periop risk of:
A. Bronchospasm
B. Laryngospasm
C. Hypoxia
D. All of the aboce
Answer: D
A viral infection within 2 - 4
weeks before general
anesthesia and endotracheal
intubation appears to place
the child at risk for
perioperative pulmonary
complications such as
bronchospasm (10 fold),
laryngospasm (5 fold),
hypoxia and atelectasis.
At term, pseudocholinesterase activity is:
A. increased by 10%
B. increased by 30%
C. Decreased by 10%
D. Decreased by 30%
Answer: Decreased by 30%
Kernicterus has been reported after the IV administration of drugs to neonates which contain the preservative:
A. Metabisulfate
B. P-amino Benzoic Acid
C. EDTA
D. Benzyl Alcohol
Answer: Benzyl Alcohol
Benzyl alcohol has been
implicated in causing
kernicterus by displacing
bilirubin from albumin and
facilitating its entry into the
brain. Certain preparations of
propofol and normal saline
flush can contain benzyl
alcohol and should be avoided
in the neonate.
Treacher Collins syndrome:
A. Results in anterior displacement of the tongue
B. Results in mandibular hyperplasia
C. Is often associated with other craniofacial abnormalities such as cleft palate
D. Follow an autosomal recessive inheritance pattern
Answer: C
craniofacial abnormalities
such as cleft palate.
Treacher-Collins syndrome is
the most common of the
mandibulofacial dysostoses.
Inheritance is as an autosomal
dominant trait. Hypoplasia of
the mandible with posterior
displacement of the tongue
(glossoptosis) can result in
early airway problems.
Treacher-Collins syndrome is
associated with cleft palate,
ventricular septal defect, and
gross deformites of the
external ear canals and
ossicular chain. These
patients present extreme
difficulty with airway
management and facilities for
surgical airway placement
should be part of the
anesthetic plan.
Nonsteroidal anti-inflammatory agents, such as ketorlac, are not recommended as analgesics during labor because they are associated with:
A. delayed closure of the ductus arterioles
B. Maternal and fetal respiratory depression
C. Suppression of uterine contractions
D. Impaired placental oxygen transfer to the fetus
Answer: C
Suppression of uterine
contractions
Nonsteroidal
antiinflammatory agents are
not recommended because
they suppress uterine
contractions and promote
closure of the fetal ductus
arteriosus.
In the patient with pregnancy induced HTN, epidural analgesia during labor has been associated with
A. Increased maternal catecholamine levels
B. Improved uterine placental blood flow
C. Increased uterine artery vasospasm
D. Fetal distress
Answer: B
Epidural analgesia is the
preferred technique for labor
analgesia in the patient with
PIH if not contraindicated by
coagulopathy. Epidural
analgesia reduces maternal
catecholamine levels and
facilitates blood pressure
control. Epidural analgesia
improves intervillous blood
flow thus improving
uteroplacental performance
and fetal well-being.
In neonates and infants, variations in cardiac output are largely the result of
A. SVR
B. SV
C. Barorecpetor reflex
D. Heart Rate
Answer: D
SV is fixed due to poorly developed and noncompliant left heart.
The cardiac output is
therefore very dependent on
heart rate. Additionally,
sympathetic nervous system
and baroreceptor reflexes are
not fully mature and less able
to compensate for changes in
blood pressure.
You are asked to evaluate a 26F complaining of headache following an uneventful vaginal delivery with continuous epidural analgesia. Likely causes of the headache:
A. injection of significant amount of air during epidural placement
B. Placement of a multihued epidural catheter
C. Use of 0.25% bupivacaine for initial injection
D. Use of fentanyl in the epidural infusion
Answer: A
Headache frequently follows
unintentional subdural
puncture in parturients.
However, a self-limited
headache may occur without
dural puncture; in such
instances, injection of
significant amounts of air into
the epidural space may be
responsible.
At term, Maternal RBC mass has:
A. decreased by up to 15%
B. Increased by up to 10%
C. Increased by up to 20%
D. Increased by up to 50%
Answer: C
The beginning of second stage of labor is defined by:
A. presence of full cervical dilation
B. Presence of active phase of labor
C. Rupture of amniotic sac
D. Presence of uterine contractions occurring at a frequency of > 2 min
Answer: A
The second stage begins with
full cervical dilatation, is
characterized by fetal descent,
and ends with complete
delivery of the fetus.
The most common metabolic abnormality in the neonate is:
A. Hypoglycemia
B. Hyponatremia
C. Hypokalemia
D. Hypoclacemia
Answer: A
Hypoglycemia is the most
common metabolic problem
occurring in the neonate.
Inadequate glycogen stores
and deficient gluconeogenesis
are important factors in the
newborn’s susceptibility to
hypoglycemia. The incidence
is highest in small-for-
gestational age neonates and
in neonates of diabetic
mothers.
During pregnancy, the level of which of the following clotting factors may be decreased:
A. VII
B. VIII
C. XI
D. XII
Answer: C.
Pregnancy is associated with
a hypercoagulable state.
Fibrinogen and factors VII,
VIII, IX, X and XII
concentrations all increase;
only factor XI may decrease.
An increase incidence of malignant hyperthermia is seen in children with:
A. Central core disease
B. Duchenne MD
C. Malignant neuroleptic syndrome
D. Cerebral Palsy
Answer A
Linkage of MH with other
diseases has been
problematic: only central core
disease appears to be truly
linked. In Duchenne’s
muscular dystrophy, the
balance of opinion has shifted
from an association with MH
to an anesthesia-induced
rhabdomyolysis. Cerebral
palsy and malignant
neuroleptic syndrome are not
associated with an increased
incidence of MH, although
malignant neuroleptic
syndrome may mimic MH
and is part of the differential
diagnosis.
Pain relief during the second stage of labor requires neural blockade from T10 to:
A. S1
B. S2
C. S3
D. S4
Answer: D
Sensory innervation of the
perineum is provided by the
pudendal nerve (S2 - S4) so
pain during the second stage
of labor involves the T10 - S4
dermatomes.
An 8kg infant is to receive GA with ETT. Current recommendations concerning preop fasting of this patient include:
A. NPO for 6-8H prior to surgery
B. Clear fluids can be given up to 1H prior to surgeyr
C. Breast milk may be given up to 4H prior to surgery
D. SOlid foods may be given up to 3H prior to surgery
Answer: C
breast milk may be given up
to 4 hours prior to surgery.
Current fasting
recommendations for children
include: Solids are prohibited
within 6 - 8 hours of surgery,
formula within 6 hours, breast
milk within 4 hours and clear
liquids within 2 hours of
surgery.
Maternal mortality associated with AFE is:
A. 10 - 20%
B. 25 - 40%
C. 50 - 75%
D. > 80%
Answer: D
At term, commonly found changes in maternal BP include:
A. little change in systolic pressure with decreased diastolic pressure
B. Increased SBP and decreased DBP
C. Decreased SBP and DBP
D. Increased SBP and DBP
Answer: A
Overall, at term, systolic
blood pressure changes little.
A decrease in diastolic blood
pressure of 15 mmHg may
occur resulting in a decrease
in mean pressure and an
increase in pulse pressure.
You are called to deliver anesthesia to an emergent C/S in a 28F 100kg female with umbilical cord prolapse. After IV induction, several attempts at ETT are unsuccessful. The most appropriate management at this time should be:
A. Transtracheal jet ventilation
B. Placement of LMA while maintaining cricoid pressure
C. awakening the pt and placement of epidural catheter
D. Obtaining a surgical airway
Answer: B
In the face of severe fetal
distress, general anesthesia is
indicated. If initial attempts at
intubation fail, ventilation
should be attempted with
either the face mask or LMA,
while continuing cricoid
pressure.
Upon delivery of a 3.2kg male, the neonate is noted to be cyanotic with a scaphoid abdomen. Auscultation of the chest reveals bowel sounds in the left hemithorax. Management of the infant should include:
A. Decompression of the stomach with a gastric tube
B. PPV by mask with 100% FIO2
C. Awake intubation and ventilation with 100% FIO2 and increased PIP to inflate left lung
D. All of the above
Answer: A
decompression of the stomach
with a orogastric tube
This neonate’s signs and
symptoms are consistent with
congenital diaphragmatic
hernia. Immediate treatment
should include decompression
of the stomach and the
administration of
supplemental oxygen.
Positive pressure by mask
should be avoided as it may
cause stomach distention and
further compromise
pulmonary function. Awake
intubation should be
performed, but positive
airway pressures should not
exceed 25 - 30 mmHg as it
can precipitate damage to the
normal lung and
pneumothorax.
The greatest strain on the maternal heart occurs:
A. during the active phase of labor
B. immediately after delivery
C. during the latent phase of labor
D. during the second stage of labor
Answer: B
The greatest strain on the
heart occurs immediately
after deilvery, when intense
uterine contraction and
involution suddenly relieve
inferior vena caval
obstruction and increse
cardiac output as much as
80% above prelabor values.
Intraop heat loss is greater in neonates than adults as a result of:
A. A larger surface area:core ratio in the neonate
B. Increased skin thickness in the neonate
C. Increased SQ adipose tissue in the neonate
D. An increased shivering response in neonates
Answer: A
Pediatric patients have a
larger surface area per
kilogram than adults. Thinner
skin and a lower fat content
also contribute to greater heat
loss in the neonate. Shivering
is not an important method of
thermogenesis in the neonate.
During pregnancy, the level of which of the following hormones steadily increases?
A. Free T4
B. Insulin
C. TSH
D. Increased T3
Answer: Insulin
In children with R to L intracardiac shunting, inhalation induction is expected to be:
A. slower than healthy children
B. Faster than healthy children
C. Unaffected by the presence of shunt
D. Faster than in healthy children when very soluble agents are used
Answer: A
A right-to-left shunt slows the
inhaled induction of
anesthesia because anesthetic
concentration in the arterial
blood increases more slowly.
A left-to-right shunt has little
effect since the decreased
delivery of anesthetic to the
target tissues negates the
increased uptake with this
type of shunt
The administration of a beta2 agonist to the laboring parturient will cause:
A. increase in uterine tone
B. Decrease in uterine tone
C. decrease in placental blood flow
D. an acceleration to the second stage of labor
Answer: B
Decrease in uterine tone.
Uterine muscle has both α-
and β-receptors. α1-Receptor
stimulation causes uterine
contraction, whereas β2-
receptor stimulation produces
relaxation..
A 26F with a history of mitral stenosis is in labor. Beneficial effects of epidural anesthesia in this patient include:
A. A mild increase in PVR
B. mild decrease in preload
C. Reduced incidence of pain-induced maternal tachycardia
D. all of the above
Answer: C
reduced incidence of pain-
induced maternal
tachycardia,.
Mitral stenosis is the most
common type of cardiac
valvular defect seen in
pregnant patients. Epidural
analgesia during labor and
delivery reduce pain-induced
tachycardia allowing more
time for left ventricular
filling. Preload should be
maintained and causes of
pulmonary vasoconstriction
(hypoxia) should be avoided.
At term, the MAC of inhaled agents is:
A. Increased by 20%
B. Increased by 40%
C. Decreased by 20%
D. Decreased by 40%
Answer: D
The most common congenital cardiac abnormality in infants and children is;
A. ASD
B. VSD
C. PDA
D. Tetralogy of Fallot
Answer: B
Ventricular septal defect is the
most common congenital
cardiac abnormality,
constituting approximately
35% of all congenital cardiac
abnormalities.
But Tetraology of Fallot is the most common CYANOTIC cardiac congenital anomalies
Breech positions
A. have little effect on fetal morbidity if vaginal delivery is accomplished
B. Are commonly seen with post-mature fetus
C. Are associated with increased incidence of cord prolapse
D. Complicate about 10% of pregnancies
Answer: C
Breech presentations
complicate 3 - 4% of
deliveries and significantly
increase both maternal and
fetal morbidity and mortality
rates. The most common
cause is prematurity. Breech
presentation also increases the
incidence of cord prolapse to
10%.
A 3.2 kg neonate is scheduled for a polyoromyotomy. The estimated blood volume of the neonate is approximately:
A. 154 mL
B. 280 mL
C. 332 mL
D. 401 mL
Answer: B
Full-term neonates have a
blood volume of 85 - 90
mL/kg. In this neonate the
EBV = 85 - 90 mL/kg x 3.2
kg = 272 - 288 mL.
Low dose (< 0.75 MAC) of volatile anesthetic agents have been shown to:
A. Cause uterine artery vasoconstriction
B. increase myometrial muscle activity
C. Cause little changes in the effects of oxytocin in the uterus
D. Cause uterine atony
Answer: C
Isoflurane, sevoflurane and
desflurane depress uterine
activity equally at equipotent
doses. Low doses (< 0.75
MAC) of these agents,
however, do not interfere with
the effect of oxytocin on the
uterus. Higher doses can
result in uterine atony and
increase blood loss at
delivery. Nitrous oxide has
minimal if any effects.
In order to maintain euglycemia in the neonate, it is recommended that IV fluid ternary include glucose infused at a rate of:
A. 3 - 5 mg/kg/hr
B. 3 - 5 mg/kg/min
C. 6-10 mg/kg/hr
D. 6 - 10 mg/kg/min
Answer: B
Neonates require 3 - 5
mg/kg/min of glucose
infusion to maintain
euglycemia; premature
neonates require 5 - 6
mg/kg/min.
At term, uterine blood flow represents approximately
A. 5% of CO
B. 10% of CO
C. 20% of CO
D. 30% of CO
Answer: B
There is an increase in cardiac
output of approximately 40%
at term and about 10% or 600
- 700 mL/min represents the
uterine blood flow.
The most common form of tracheoesophageal fistula consists of:
A. A blind upper esophageal pouch with no fistula between the esophagus and the tracheal
B. Blind upper esophagus pouch with fistula between the trachea and distal esophagus
C. Fistula between a blind upper esophagus pouch and trachea
D. Fistula between the trachea and an otherwise normal esophagus
Answer: B
Approximately 86% of
tracheoesophageal fistulas are
of Type III B, consisting of a
blind upper esophageal pouch
and a tracheal fistula
connecting to the distal
esophagus. Anesthetic
management ideally consists
of an awake intubation with
placement of the ETT distal
to the fistula, but above the
carina.
In contrast to the single-hole epidural catheter, the multihued catheter
A. Requires a shorter depth of insertion
B. Is associated with lower incidence of unilateral block
C. Increases the incidence of false-negative aspiration for intravascular placement
Answer: B
Use of a multiholed catheter
appears to be associated with
fewer unilateral blocks and
greatly reduces the incidence
of false-negative aspiration
for intravascular catheter
placement. Advancing a
multiholed catheter 7 - 8 cm
into the epidural space
appears to be optimal for
obtaining adequate sensory
levels.
Hyoercyanotic attacks associated with Tetrology of Fallot are best treated with:
A. Epinephrine
B. Isoproterenol
C. Phenylephrine
D. Nitroglycerin
Answer: Phenylephrine
Treatment of hypercyanotic
attacks is influenced by the
cause of the pulmonary
outflow obstruction.
When symptoms reflect a dynamic
infundibular obstruction,
beta-blockers are appropriate
treatment.
If the cause is decreased systemic vascular
resistance, treatment is intravenous fluids and/or
phenylephrine.
Sympathomimetic drugs with
β-agonistic properties or
vasodilators should not be
used.
In the absence of drug administration, sustained decreased baseline variability in the fetal heart rate suggests:
A. Normal progress from latent to active phase of labor
B. Normal progress from first to second stage of labor
C. Full development of neuronal pathways of the vagus nerve
D. Fetal distress
Answer: D
Fetal heart rate varies 5 to 20
bpm in the normal fetus. Fetal
distress due to arterial
hypoxemia, acidosis or CNS
damage is associated with
minimal to absent beat-to-
beat variability.
Compared to a 3 month old, the MAC of desflurane required to anesthetize a full term neonate is
A. 10% greater
B. 25% greater
C. 10% Less
D. 25% Less
Answer: D
Full-term neonates require
lower concentrations of
volatile anesthetics than do
infants 1 - 6 months of age.
The MAC is about 25% less
in neonates than in infants.
Furthermore, MAC in preterm
neonates is less than full-term
neonates. MAC steadily
increases until 2 - 3 months of
age and then steadily declines
with age.
The greatest risk factor for placenta previa is:
A. Prematurity
B. Polyhydraminos
C. Nullparity
D. Previous C/sections
Answer: D
The greatest risk factor for
placenta previa is previous
cesarean section. Other risk
factors include previous
uterine myomectomy,
multiparity, advanced
maternal age and a large
placenta.
Obstruction of the IVC by the enlarging uterus results in:
A. decreased blood volume in the epidural venous plexus
B. decreased spinal CSF volume
C. Increased potential volume of the epidural space
D. Decreased epidural space pressure
Answer: B
Obstruction of the inferior
vena cava by the enlarging
uterus distends the epidural
venous plexus and increases
epidural blood volume. The
latter has three major effects:
(1) decreased CSF volume,
(2) decreased potential
volume of the epidural space
and
(3) increased epidural
space pressure.
During Labor, continuous epidural analgesia with 0.1% bupivacaine with fentanyl 5 mcg/ mL has been associated with:
A. increased risk of C/s
B. increased rate of forceps deliver
C. Decreasd efficacy of oxytocin
D. Minimal or no change in duration of labor
Answer D
Current techniques employing
dilute combinations of local
anesthetic and opioid for
epidural analgesia do not
appear to prolong labor or
increase the likelihood of
cesarean section.
As compared to patients with gastroschisis, patients with omphalocele:
A. rarely have any other congenital defects
B. lack a peritoneal covering of the abdominal contents
C. Have a midline defect at the base of the umbilical cord
D. are usually delivered after 42 weeks
Answer: C
have a midline defect at the
base of the umbilical cord.
Omphalocele manifests as
external herniation of
abdominal viscera through the
base of the umbilical cord.
The abdominal contents are
contained within a sac formed
from the peritoneal membrane
without overlying skin.
Omphalocele is associated
with a 75% incidence of other
congenital defects.
Approximately 33% of
neonates with omphaloceles
are preterm.
During pregnancy, uterine blood flow is directly proportional to
A. difference between arterial and venous pressures
B. Uterine vascular resistance
C. Uterine venous pressure
D. Degree of endogenous catecholamines
Answer: A
Uterine blood flow is directly
proportional to the difference
between uterine arterial and
venous pressures, but
inversely proportional to
uterine vascular resistance.
Stress-induced release of
endogenous catecholamines
can cause uterine
vasoconstriction and reduce
uterine blood flow.
A 3 month old is scheduled for correction of tetralogy of Fallot. Induction of anesthesia is best accompanied by:
A. Thiopental
B. Isoflurane
C. Desflurane
D. Ketamine
Answer: Ketamine
Induction of anesthesia in
patients with tetralogy of
Fallot is often accomplished
with intravenous or
intramuscular ketamine. The
onset of anesthesia after
ketamine injection may be
associated with improved
oxygenation, presumably
reflecting increased
pulmonary blood flow due to
ketamine-induced increases in
systemic vascular resistance.
In the parturient, the most common complication of regional anesthesia is
A. unintentional intravascular injection
B. unintentional intrathecal Injection
C. HoTN
D. Postural puncture headache
Answer: C
Hypotension is the most
common complication of
regional anesthesia. It is
primarily due to decreased
sympathetic tone and is
greatly accentuated by
aortocaval compression.
During pregnancy, the P-50 curve of maternal hemoglobin:
A. increases to about 30 mmHg
B. Increases to about 40 mmHg
C. Remains unchanged
D. Decreases to about 23 mmHg
Answer: A
During pregnancy, the P-50
for the maternal hemoglobin
increases from 27 to 30
mmHg; the combination of
this and increased cardiac
output enhances oxygen
delivery to tissues and
placenta.
Placenta Accreta:
A. is associated with massive hemorrhage from manual extraction of the placenta
B. Is rarely seen in patients with placenta previa
C. Involves invasion of the placenta into the myometrium
D. Is not associated with previous C/s
Answer: A
is associated with massive
hemorrhage from manual
extraction of the placenta.
Placenta accreta is an
adherent placenta that has not
invaded the myometrium.
Massive hemorrhage may
occur when removal of the
placenta is attempted after
delivery. Risk factors include
placenta previa and previous
cesarean delivery.
The heart rate racing below is:
A. suggestive of fetal distress
B. Suggestive of fetal head compression
C. Suggestive of fetal cod compression
D. A reassuring tracing
Answer: A
Suggestive of fetal distress.
This tracing is indicative of
late decelerations. Late
decelerations are
characterized by the slowing
of the fetal heart rate that
begins 10 - 30 seconds after
the onset of uterine
contractions. Late
decelerations are associated
with fetal distress.
As compared to an adult, the alveolar uptake of inhalationall anesthetics is greater in the neonate as a result of:
A. A greater MV to FRC ratio in the neonate
B. the smaller cardiac output
C. Increased blood solubility of the agent in the neonate
D. Increased dead space to shunt ratio in the neonate
Answer: A
a greater minute ventilation to
FRC ratio in the neonate.
Uptake of inhaled anesthetics
is more rapid in infants than
in older children or adults.
This accelerated uptake most
likely reflects the infant’s high
alveolar ventilation relative to
functional residual capacity
Complications associated with oxytocin administration include:
A. Maternal water intoxication
B. Uterine Atony
C. hypertension with rapid infusion
D. All of the above
Answer: C
Complications of oxytocin
administration include fetal
distress due to
hyperstimulation, uterine
tetany and maternal water
intoxication. Rapid
intravenous infusion can also
cause transient systemic
hypotension due to relaxation
of vascular smooth muscle.
Anesthetic care of the neonate undergoing correction for gastroschisis should include:
A. Maintenance of adequate hydration with 4 mL/kg/hr of crystalloid solution
B. The use of nitrous oxide to hasten emergence and extubation
C. The avoidance of of muscle relaxation
D. Periop hydration with both crystalloid and colloid solutions
Answer: D
preoperative hydration with
both crystalloid and colloid
solutions.
Preoperative fluid
management will require 2 - 4
times the usual daily
maintenance (8 - 16
mL/kg/hour) These neonates
experience considerable
protein loss. To maintain
normal oncotic pressures,
protein containing solutions
should constitute
approximately 25% of the
replacement fluids. Repair of
large defects will require
maximal muscle relaxation
both intraoperatively and
postoperatively. Nitrous oxide
is avoided because of its
ability to diffuse into the
intestinal tract making closure
more difficult.
The sensory level required to produce adequate anesthesia for C-section is:
A. T4
B. T6
C. T8
D. T10
Answer: A
Cesarean section requires a
T4 sensory level. Because of
the high sympathetic
blockade, all patients should
receive a 1000 - 1500 mL
bolus of lactated Ringer’s
prior to neural blockade.
Epiglottitis is:
A. effectively treated with nebulized racemic Epi
B. Best managed with an awake intubatiojn
C. most commonly secondary to viral infection of the trachea
D. Associated with inflammation of all supraglottic structures
Answer: D
Acute epiglottitis is a
bacterial infection affecting
all supraglottic structures. In
children, it is best managed
with a slow inhalational
induction followed by
intubation. Preparedness for
emergent tracheostomy is
essential.
Vascular components of the umbilical cord include:
A. One umbilical artery and one umbilical vein
B. One umilical artery and two umbilical veins
C. Two umbilical arteries and one umbilical vein
D. Two umbilical arteries and two umbilical veins
Answer: C
Fetal blood flow within the
placenta is derived from the
umbilical cord via two
umbilical arteries and returns
to the fetus via a single
umbilical vein.
The diagram below is consistent with:
A. Normal neonatal anatomy
B. Tetralogy of Fallot
C. Transposition of the great vessels
D. Truncus arteriosus
Answer: C
Five minutes after delivery of a 3.25kgM, the following is observed:
Pulse: 122
Actively Crying
Active flexion and extension with stimulation and acrocyanosis
What is his Apgar score?
A. 7
B. 8
C. 9
D. 10
Answer: 9
Respiratory parameters that are increased during pregnancy include:
A. Airway resistance
B. Tidal Volume
C. FRC
D. PaCO2
Answer: B
Oxygen consumption and
minute ventilation
progressively increase during
pregnancy. Both tidal volume
and rate increase. PaCO2
decreases and PaO2 increases
slightly. Airway resistance
declines about 35% during
pregnancy and FRC is
reduced by approximately
20%.
Carbaprost:
A. Causes uterine relaxation
B. Should only be administered IM
C. Should only be given prior to delivery
D. Is effective in reducing need for C/S
Answer: B
Carboprost tromethamine is a
synthetic analogue of
prostaglandin F2 that
stimulates uterine contraction.
it is often used to treat
refractory post partum
hemorrhage. As with
methergine, it should be
administered only
intramuscularly.
The blood/gas coefficient for volatile anesthetics:
A. Are greater in the neonate than the adult
B. Are less in the neonate than the adult
C. Remain unchanged regardless of age
D. Are increased in preterm neonates but normal in full term neonates
Answer: B
The blood/gas coefficients of
volatile anesthetics are lower
in neonates than in adults,
resulting in even faster
induction times and
potentially increasing the risk
of overdosing.
In contrast to placenta previa, abruptio placentae:
A. Usually occurs after 32 weeks of gestation
B. Is associated with abdominal pain
C. Poses little risk to the developing fetus
D. Is not associated with coagulopathy
Answer: B
The signs and symptoms of
abruptio placentae are
variable, but abdominal pain
is always present, whereas
placenta previa is associated
with painless vaginal
bleeding. Shock,
coagulopathy, acute renal
failure and fetal distress are
also associated with abruptio
placentae. Abruptio placentae
is usually seen earlier in the
pregnancy, after 20 weeks of
gestation.
Metabolic defects commonly seen in infants with pyloric stenosis include:
A. Hypokalemia
B. Acidosis
C. Hyperchloremia
D. Hypernatremia
A. Hypokalemia
Persistent vomiting results in
the progressive loss of gastric
fluid, which contains sodium,
potassium, chloride and
hydrogen. Renal pH
compensation causes further
loss of potassium. These
patients are dehydrated,
hypokalemic and alkalotic.
Hyponatremia may also be
present.
Volatile anesthetic agents cross the placenta and enter fetal circulation via
A. Breaks in the placental membrane
B. Bulk Flow
C. Pinocytosis
D. Diffusion
Answer: D
Placental exchange can occur
by one of five mechanisms:
diffusion, bulk flow, active
transport, pinocytosis and
breaks in the placental
membrane. Most drugs used
in anesthesia have molecular
weights well under 1000 and
consequently can diffuse
across the placenta.
Neonatal changes occur upon delivery include:
A. Lung expansion by creation of negative 40 - 60 cmH2O intrathoracic pressure
B. Anatomic closure of the ductus arteriosus
C. Increased PVR secondary to lung resistance
D. Increased thermogenesis from shivering
Answer: A
A 45 gestational week old neonate is scheduled for repair of a myelomeningocele. Anesthetic considerations include:
A. RSI with patient in supine position
B. Use of Deep NMB to prevent intraop movement
C. Awake intubation in the lateral position
D. Use of radiant warmers to prevent heat loss from the myelomeningocele.
Answer: C
Toggle Masks
Extra 1
Awake intubation in the
lateral position is performed
to avoid pressure on the
meningocele sac. Long-acting
muscle relaxants are avoided,
allowing the surgeon to use
nerve stimulators to identify
functional neural elements.
Although hypothermia is a
frequent complication, care
must be taken to prevent
drying or thermal injury to the
exposed neural tissue by the
use of radiant heat lamps.
Congenital Heart diseases associated with cyanosis include:
A. Eisenmenger’s syndrome
B. VSD
C. PDA
D. Coarctation of the Aorta
Answer: A
Patients with long-standing
left-to-right intracardiac
shunting may eventually
develop increased pulmonary
vascular resistance. When that
resistance exceeds the
systemic vascular resistance a
reversal of the shunting can
occur. These patients are said
to have Eisenmenger’s
syndrome.
Following the use of epidural morphine for postoperative analgesia after C/s, several studies have reported increased incidence of:
A. Abdominal pain
B. Recurrent herpes simplex labials infection
C. Septicemia
D. Thrombocytopenia
Answer B
An increased incidence (3.5 -
30%) of recurrent herpes
simplex labialis infection had
been reported 2 - 5 days
following epidural morphine.
In the flow-volume loops below, normal is represented by B. The loop that best describes the maternal respiratory pattern during the third trimester is:
A
B
C
D
Answer: B
Flow-volume loops are
unaffected by pregnancy and
airway resistance decreases
by about 35%.
