FCA Obstetric Questions

Question 1

Discuss the use of regional anaesthesia in eclamptic and pre-eclamptic parturients for caesarean section.

Question 2

Describe how cardiopulmonary resuscitation differs in a 32-week pregnant patient in comparison to a normal adult.

Question 3

Indicate, by means of an algorithm, the steps you would follow in the resuscitation of a newborn baby.

Question 4

Describe the mechanism of action of Vasopressin.

Question 5

Describe the haemodynamic changes that occur during spontaneous vaginal delivery, both with and without analgesia.

Question 6

Describe the haemodynamic changes that occur during caesarean section, under both neuraxial and general anaesthesia.

Question 7

A parturient presents at 35 weeks gestation, for a routine antenatal visit. She had a mitral valve replacement, and takes warfarin daily. She is currently NYHA II (New York Heart Association II) for dispnea. The obstetrician has asked for your advice on how to manage her further. Describe the advice that you would give the obstetrician.

Question 8

What are the risks involved in performing a lumbar epidural on a labouring parturient, and how can these risks be prevented?

Question 9

How may an epidural for labour be converted to anaesthesia for caesarean section

Question 10

Why does central neuraxial anaesthesia sometimes fail to work, and how can this failure be prevented

Question 11

A 25-year-old para 2 gravida 3 with an atrial septal defect measuring 24 mm, severe pulmonary hypertension, and an ejection fraction of 62% is not cyanosed,nor is she in heart failure. She is scheduled for surgical delivery.
What problems can you expect during anaesthesia?
Outline your anaesthetic plan for this patient.

Question 12

Address the following controversies in obstetric anaesthesia

a) The effects of epidural analgesia in labour on the progress and outcome of labour. (40)
b) Phenylephrine versus ephedrine for the management of spinal hypotension during Caesarean section.

Question 13

a) Draw the left ventricular pressure volume loop for a patient with clinically significant mitral regurgitation. (6)
b) List the reasons for improvement of symptoms of mitral regurgitation during pregnancy.

Answer 14

a) Draw the left ventricular pressure volume loop for a patient with clinically significant mitral stenosis. (6)
b) List the reasons for worsening of symptoms of mitral stenosis during pregnancy.

Question 15

A patient presents at 37 weeks’ gestation with dyspnoea and bilateral opacification on her chest radiograph.

i) How would you establish the diagnosis? (30)
ii) Discuss the pre-and intra-operative management of a patient with an established diagnosis of severe peripartum cardiomyopathy, who requires caesarean delivery. (45) [100]

Question 16

Briefly classify cardiomyopathies and give examples in each category. (25

Question 17

A young, healthy woman develops a headache 18 hours after a spinal anaesthetic for elective caesarean section

a) Discuss the clinical features and diagnosis of a post-dural puncture headache. (20)
b) Describe in detail your approach to the management of this complication. (80)

Question 18

A healthy, 26-year-old woman is at term following an uncomplicated pregnancy. The patient has a structurally and functionally normal heart and is booked for an elective Caesarean section following a Caesarean section in her only previous pregnancy, performed for presumed cephalo-pelvic disproportion. This case was planned for 08h00 but due to numerous emergency Caesarean sections, only receives anaesthesia at 15h30. Following a routine subarachnoid (spinal) anaesthetic with 10mg hyperbaric bupivacaine and 10 micrograms fentanyl, a 30% decrease in the mean arterial pressure (hypotension) occurs soon after surgery starts a) b) c) d) e) 3

a) Discuss in detail the various physiological, and pathophysiological factors (including those related to the subarachnoid anaesthesia) that could contribute to produce hypotension in this patient. (20)
b) Detail what pre-emptive steps could have been taken to decrease the incidence and degree of hypotension experienced by this patient. (15)
c) What differential diagnoses would you need to entertain in this patient in the clinical scenario where pathologies, other than the subarachnoid anaesthesia, need to be considered as a potential cause for the hypotension? (10)
d) Assuming you have a population of healthy parturients at term, briefly describe (or tabulate), the different clinical scenarios (combinations of blood pressure, heart rate, systemic vascular resistance) and probable associated cardiac output changes (from baseline) that can occur or result when this population shows a 30% decrease in mean arterial pressure following subarachnoid anaesthesia. For each of the clinical scenarios you list, describe your management of the hypotension scenarios giving specific dosage regimes and therapy escalation plans. (35)
e) Assume for each scenario (in section (d) above) your initial management is successful and the blood pressure returns to its pre-anaesthesia baseline, briefly describe how you understand your management plan to have contributed to this correction (including dominant pharmacodynamic mechanisms for drugs), describing the effect(s) of your management and the expected time for your interventions to take effect. (20) [100]

Question 19

A 20-year-old patient with a molar pregnancy with lung metastases is presented for evacuation of the uterus. She is not actively bleeding, has an Hb of 10g/dl, blood pressure of 160/50 mmHg, heart rate of 130 per minute and temperature of 39oC

a) List the differential diagnosis. (10)
b) List and motivate the salient aspects of your clinical examination and special investigations in this case. (25)
c) Discuss your pre-operative preparation of this patient and end-points of resuscitation. (25)
d) Discuss your intra-operative management of this patient. (40) [100]

Question 20

A 26-year-old primigravida at 34 weeks gestation is admitted to the labour ward. Her admission BP is 170/110 mmHg. She complains of headache and epigastric pain. a) b) c)
Define severe preeclampsia, and indicate the relevant diagnostic criteria. (5)
What are the organ system effects associated with, and important considerations in the management of severe preeclampsia? (15)
Discuss the anaesthetic management of this patient if she presents in pulmonary oedema for caesarean delivery for a non-reassuring fetal heart trace. (30) [50]

Question 21

Ms JW is a 25-year-old female with a history of two previous caesarean sections and a current ultrasound diagnosis of Placenta Praevia for which an elective caesarean section is scheduled at 38 weeks. During your morning preoperative assessment, an elder from her church presents you with a signed form stating that, owing to her religious beliefs (Jehovah’s Witness), Ms JW refuses a blood transfusion during her medical care. Describe your approach to this situation under the following headings

a) The risk of haemorrhage.
b) i) The validity of the consent form presented to you by the elder, regarding the refusal of blood products. (3)
ii) Under what circumstances can or can’t you administer blood despite this document? (3)
c) List blood conservation strategies and alternatives to blood transfusion and indicate their acceptability to Jehovah’s Witness patients. (15)
d) How would you obtain informed consent from the patient? (20)
e) The rights of other parties in this scenario
i) The fetus. (4)
ii) The father. (2)
iii) The church elder.

Answer 21

Marking Memorandum Risk of haemorrhage (2) (1/2 a mark for each point in this section. 1 mark per point elsewhere) 1) very high a) 2 x previous C/S and placenta praevia. i) Placenta increta/accreta b) High risk of caesarean hysterectomy Validity of refusal and circumstances to transfuse. (6) Alternatives to transfusion (15) 1) Acceptable to all JW Patients a) Crystalloids b) Artificial colloids c) Perioperative hypervolaemic haemodilution d) Preoperative optimisation of Hb level i) Iron ii) Folate iii) Eythryopoietin e) Minimising intraoperative blood loss i) Hypotensive anaesthesia ii) Tranexamic acid iii) Surgical techniques f) Postoperative optimisation of Hb Level i) As above g) General Measures to avoid bleeding i) Avoid hypothermia/ avoid acidosis/stop anticoagulants 2) “Matters of conscience” a) Cell saver i) Will need to maintain “complete circuit” to be acceptable ii) Note concerns in obstetric use (1) Amniotic fluid embolism (2) Meconium contamination i) Infective risks b) Intraoperative normovolaemic haemodilution i) Will need to maintain “complete circuit” to be acceptable ii) Rarely useful in obstetrics due to prexisting anaemia c) Albumin d) Blood fractions e) Recombinant products f) Haemoglobin substitutes 3) Unacceptable to JW patients a) Preoperative autologous donation Obtaining informed consent (20) (1 mark for each point or subpoint, more than 20 marks available in this section, as getting 10 of these points regarded as sufficient for a pass) 1) Private discussion with patient away from external influences a. Ensure understanding that her own wishes are important, not those of others b. Ensure respectful treatment of her beliefs c. Ensure the patient understands the full gravity of situation and her decision. i. As examples(only 1 mark available for examples, similar examples score) : 1. Her own death may be end result of lack of transfusion a. Child will grow up without mother 2. Baby may be compromised by maternal refusal to receive blood d. Ensure appreciation/understanding of the alternatives to transfusion e. Ensure in language she can understand i. Use of appropriate interpreter where required f. Ensure appropriate witnesses at discussion g. Ensure competency of patient i. Age//Legal Status/Understanding (1/2 mark for each issue that affects competency) Consent can be withdrawn/altered at any time Engagement with hospital liaison committee a. Ensure patient has a full understanding of her belief system b. 3) 4) 5) 6) 7) Can assist patient with decision on “matters of conscience” Ensure JW “no blood” card appropriately signed and dated Ensure hospital consent forms signed and witnessed correctly a. As per local policy b. Some facilities have separate blood consent forms to surgical forms Inform surgeon/theatre team a. Issues for surgical theatre team (1/2 mark for each issue that theatre team) i. Surgical participation in risk/benefit and alternatives discussion ii. iii. iv. Documents a. Best possible blood conservation strategy Implementation of quoted surgical techniques Availability of suitable equipment examples: 1. cell saver equipment/disposables 2. Specialised surgical equipment Patient’s signature is the true consent, the witnesses confirm the signature and assent of the patient b. c. Ensure two witnesses Support with JW “no blood card” if desired Doctor has right to refuse participation in this elective case if manages this case conflicts with his own value/belief system, a. Is obliged to assist patient with finding someone willing to help Rights of other parties (7) 1) 2) 3) Fetus a) b) c) ethical debate

i) mother probably overrides fetal needs once baby is born courts would probably order a transfusion of baby if anaemic
i) Blood can be given to baby in emergency to save baby life without court order Courts unlikely to order transfusion of mother against her wishes even to save baby Father
a) No direct right to order or refuse a transfusion for his wife
b) Could be used as a proxy to convey desires of mother in event of coma Elder of church
a) No direct authority over consent process b) Can help interpret beliefs and matters of conscience.

Question 22

List the peri-operative concerns of uncorrected mitral stenosis in a patient for elective caesarean section

Question 23

Write short notes on labour epidural – associated fever under the following headings

a) Definition and differential diagnosis. (6)
b) Mechanisms.

Question 24

Question 4

a) Discuss the use of intra-thecal opioids in caesarean section delivery. (5)
b) Discuss the pharmacokinetics of intra-thecal morphine. (5)

Question 25

Regarding the peri-operative blood pressure management of the severe pre-eclamptic and eclamptic patient

a) Briefly discuss the underlying physiological principles. (5) ___
b) List the goals of management.

Question 26

You are the anaesthetist covering labour ward when you are called to assist with the management of a 35-year-old term primigravida in labour, who has developed a suspected amniotic fluid embolism (AFE) a) Discuss the proposed pathogenesis of AFE. (10)

b) Describe the clinical presentation of AFE and list a differential diagnosis. (20)
c) Discuss your management of a patient with AFE. (15)
d) List 5 ways in which cardio-pulmonary resuscitation should be modified when performed in a pregnant patient. (5)

Question 27

A woman known to have hypertrophic obstructive cardiomyopathy (HOCM) is booked for an elective caesarean section at 38 weeks gestation a) What are the cardiac structural abnormalities associated with HOCM? (2)
What are the cardiac structural abnormalities associated with HOCM? (2)
b) What are the haemodynamic goals when administering anaesthesia for the caesarean section in this patient?
c) What are the problems associated with giving oxytocin at delivery to this patien

Question 28

You are presented with a patient who has New York Heart Association Class III heart failure. She is suspected to have peripartum cardiomyopathy. She is at term and presents in the first stage of labour. Discuss your peripartum management of this patient under the following headings a) Definition, incidence in South Africa, and aetiology of peripartum cardiomyopathy. (5)

b) List a differential diagnosis for this patient. (10)
c) During your clinical assessment, clinical symptoms and signs would you expect in a NYHA 111 peripartum cardiomyopathy patient. (5)
d) What special investigations would be required to exclude other causes of peripartum heart failure? (5)
e) The patient is planned for normal vaginal delivery. Write notes on anaesthetic management of labour analgesia in this patient. (25) [50]

Question 29

You are consenting a young primigravida in labour, for labour epidural analgesia a) Describe how you would consent this patient for an epidural, including the risks of the procedure. (7)
What problems exist when obtaining consent from this patient for an epidural?

Question 30

Question 1 Critically evaluate the safety and efficacy of the following modalities for labour analgesia. a) Remifentanil patient controlled analgesia (PCA) pump. (5) ___
b) Single shot spinal anaesthetic.

Question 31

Question 8 11 A 25-year-old parturient at term in her third pregnancy presents with a blood pressure of 155/115 mmHg a) What other parameters are required to make a diagnosis of pre-eclampsia? (5) The parturient goes into labour overnight and presents for a caesarean section
b) What features on pre-operative evaluation would make you consider general rather than neuraxial anaesthesia?

Question 32

Question 20 26 a) Define the stages of labour and describe the transmission of nociceptive stimuli to the spinal cord (“pain pathways”) in each phase of labour as well as during caesarean section. (8)
b) A patient has a third degree tear after vaginal delivery. List two locoregional techniques that may be used to facilitate a repair.

Question 33

Question 1
You are obtaining consent for epidural analgesia from a parturient in labour. Define and quantify 5 of the most pertinent risks of this procedure.