O&G Flashcards
[21B02] A patient is admitted to hospital following diagnosis of intrauterine fetal death at 35 weeks gestation. Discuss your considerations for the anaesthetic management of her labour and delivery.
IUFD
5-7/1000 deliveries
Causes:
Ante: malf, inf, APH, PET, DM
Intra: abruption, infection, prolapse, rupture
Placental
Cord
Infection
Uterus
- Distressing
- Quiet room, isolated
- 1:1 midw care - Pain
- Entonox
- Parenteral opioids
- Epidural (excl coag)
- Other - Causing/timing
- ?ix
- ?genetic counselling - ? sepsis and coagulopathy
- FBC/Coags/CHEM20/CRP - Mode
- GA usually best option
Ex Report:
Distressing
Welfare
Multidisciplinary
Causes/timing
Sepsis and coag
[20B06] A 30-year old woman at full term collapses in early labour and is unresponsive.
a) List the most likely cause of her collapse (30%)
b) A presumptive Dx of AFE is made. Describe the immediate and ongoing MNG of this patient (70%)
[09A08] Outline the features and clinical management of AFE
AFE
Causes of maternal collapse (early labour)
- common - vasovagal, high NA, LAST, haem, HTN
- uncommon - PE, AFE, uterine rup, cardiac, cerebral, anaphylaxis
V S L H H
HEALO
haem/emb/ana/last
AFE:
MOA: ?anaphylactoid response to fetal tissue –> imm resp (C3/C4)
Path: intense pulmonary VC –> RHF/low O2/high CO2/pH low –> LHF/APO
Ix: hypofibrinogenaemia*
Ex report:
1. use of mag
2. BP monitoring/control
3. appropriate ix
4. mod GA - blunting resp to intubation, managing emergence/extu
OBSTETRICS – SEVERE PET / ECLAMPSIA *Repeat x4
[20A14] A 22yo primip at 31 weeks gestation is admitted to hospital with severe PET. Her BP is 180/115mmHg.
- Describe the symptoms and signs she may have due to her PET (50%) - Outline the appropriate immediate management of this patient (50%)
Def
HTN: 140 /or/ 90
PIH: after 20 weeks
PET: PIH + proteinuria
Severe PET: PET + any
1. 160 /or/ 110
2. pulm oedema / resp compromise
** 1/200 **
PET signs
A: oedema
B: pulm oedema - low alb/HTN
C: hypovol, inc SVR, hyperdynamic, HTN, LV dys
D: seizures, ICH, ICP
E: renal/coag/HELLP
Mx
1. Seizure: A/B/C
- MAG 4g/10min, 1g/hr for 24h - aim 2-3.5mmol *2-4mmol (MCQ)
- BP - labetalol –> nifedipine (if asthma) –> hydralazine
- Fluids - IV deplete vs full TBW –> IVF 80mL/hr, UO IDC
- Monitor - BP, IAL, MDT
GA CS
- AW AX - ETT +/- VL +/- AFOI
- alf/prop/sux
OBSTETRICS – POST DURAL PUNCTURE HEADACHE
[19B02] Evaluate options for managing a confirmed PDPH in an obstetric patient.
[11B04] While performing an epidural for labour analgesia in an otherwise healthy primip in 1st stage of labour, you inadvertently cause a dural puncture with a Touhey needle. Discuss your management of this complication.
0.2-1%
60-90% post epidural DP
Compl
1. SDH
2. Seziures
3. Sagittal sinus thrombosis
Initial mx x3
1. IT catheter
Pros: immediate, no 2nd
Cons: labour intensive, inf risk
2. Reinsert
Pros: epidiral
Cons: ?2nd DP, ?IT spread via DP
3. Remi PCA
Pros: good PK, rapid met, good timing
Cons: SE, SpO2 mon, less eff
4. N2O, IM opioids
OBSTETRICS – ANTEPARTUM HAEMORRHAGE
[16B03] A 30yo female at term requires a general anaesthetic for LSCS for significant antepartum haemorrhage. Discuss how antepartum haemorrhage affects your perioperative management.
(59.9%)
Ax degree of urgency
- Hx - blood loss, pain, JW
- Ex - BP, low BP sx, cold/pale
- Ix - CTG
Blood bank
OT
obs
Plan for
1. Reus/instab
- O2 +/- I+V if obtunded
- 2x large bore (14G)
- fluid reus
- UO + IAL
2. Transfusion
- x-match
3. Aortocaval comp
- L lat tilt
4. RSI + plan for DA/DI
- hypovol/coagulo
Key
1. Surgical control
2. Reus
3. Correct coag +/- TXA
- triad- acid/coag/hypotherm
OBSTETRICS – POSTPARTUM HAEMORRHAGE
[15A06] You are called to see a 30-year-old woman who has collapsed 2 hours post normal vaginal delivery. - What is the differential diagnosis? (30%)
- Outline the clinical features and investigations that would support a diagnosis of
postpartum haemorrhage. (70%)
(71.5%)
(71.5%) Candidates were expected to mention the following
1. The potential Obstetric and non-obstetric causes of collapse
Obs: PPH - 4T - tone > trauma > tissue > thrombin
AFE
- Investigations consistent with PPH.
Hx - TTTT
Ex - CVS/Resp/CNS
Ix - ECG/FBC/coag/abs
+
Emergency - no time
Physio changes of preg
Unfaste97849———————r
Avoid triad - hypother/acidosis/coag
Anaes
Simul dx and mx
Uterotonics
Rapid infusor/blood/IAL/TX/cell salvage/rF7a
Surgical control of bleeding
Early ETT / titrate induction (accept 78-aspiration risk) / ketamine
OBSTETRICS – OBESITY
[13A07] A 25 year old woman at 28 weeks gestation, with a body mass index (BMI) of 45 attends the high risk obstetric clinic. Outline the pathophysiology of morbid obesity affecting pregnancy and describe the implications for obstetric anaesthetic care.
[09B13] You see a 28-year-old woman at the pre-admission clinic who is 32 weeks
pregnant. She weighs 150kg and has gestational diabetes. She is hoping to have a normal vaginal delivery at term.
1. What are the issues you would discuss with her during the appointment? (50%)
2. What would you recommend for her management when she goes in to labour? (50%)
Obesity
BMI > 30
MO
BMI > 40 or 35+comorbid
Issues to discuss
Ante:
1. GDM
2. Comorbid
3. Fetal
Intra:
1. Potential for IOL
2. Instrumental
3. LSCS (CS 50% in BMI 50)
4. Foetal issues
Post:
1. Delayed wound healing
2. Support
3. LT neonatal conseq
Labour plan
1. MDT, obs referral
2. Early IV access
3. Early epidural
- failure 25%
- DP risk if >6cm dil
4. Obs med for GDM/PET
5. CS - hovermat, ramp
Anaes
1. Regional - difficult, displ
2. GA - AW, Resp
3. Drugs - Sux TBW prop LBW
4. Others - TEDS/SCUDs/HDU
OBSTETRICS – ADEQUACY OF BLOCK
[12A05] A healthy 28-year-old primigravida is scheduled for elective lower segment caesarean section for breech presentation at 39 weeks gestation.
You have performed a spinal anaesthetic using 0.5% bupivacaine 2.2 ml and fentanyl 15 μg (total volume 2.5 ml).
1. Describe the issues in assessing adequacy of the block for the planned surgery (50%)
2. Describe the options for managing an inadequate block recognised prior to commencement of surgery (50%)
(63.2%) Key components of a response to this question included:
Block adequacy
o - level of block required
Skin T11 - L1
Uterus T10 - L1
Peritoneal T4
o - modality and nature of change used to assess the level of the block
o - timing of testing
o - maternal expectations -
Management of inadequate block
o - acknowledgement that the procedure is elective
o - consideration of the cause:
drug error,
technique failure which might influence decision-making
o - waiting then retesting
o - re-performance of spinal or combined spinal/epidural
o - conversion to general anaesthesia
A description of the technique of spinal anaesthesia was not required.
OBSTETRICS – LEG NUMBNESS
[11A05] (a) How would you clinically assess a patient complaining of leg numbness the day after a spinal anaesthetic for an emergency caesarean section? (70%) (b) How would you manage the situation? (30%)
OBSTETRICS – CPR IN PREGNANCY.
[10B08] How and why is cardiopulmonary resuscitation modified for the pregnant patient at term compared with the non- pregnant patient?
- AC compression
- Resp changes = early int
- Dec FRC –> rapid desat
- Reflux/asp
- CWC dec
==> RSI+Cric - AW mx
Drug/defib protocol
- same
- fetal scalp off before shock
Urgent delivery
- if ROSC not <4mins
- relieve AC comp and diaphragm splinting
*Foetus delivered within 5 mins
Cause: cardiac > VTE > Mag tox/PET/PE/AFE/total spinal
OBSTETRICS – MYOTONIC DYSTROPHY
[10A05] A 26 year old woman with subclinical myotonic dystrophy presents to the high risk obstetric clinic. She is 25 weeks pregnant in her first pregnancy and otherwise well. She hopes for a normal vaginal delivery.
Describe and justify your recommendations for the management of her analgesia for labour and the perioperative management of any potential operative delivery.
PR 52.4%
MD
1. resp
- diaphragm weak
- aw muscle weak
–> risk of asp
2. cardiac - CM/rate
3. GI - hypom
–> aspiration
4. Uterine atony
Ix
5. Insulin resistance, hypothyroidism, adrenal insuff, MVP
- ECHO - MVP (20%)
- RFTs - RLD (spiro) / OSA (ss)
Labour > GA
1. Asp
2. sens to opioids
3. No sux, no neo
Labour plan
1. Early eip
2. Pacing if conduction def
3. Fundal ?provoke myotonia
Periop
- epi top-up
GA
1. Premed - prokin/rani
2. RSI - prop/roc/alf
- sux = rhabdo
- antiACh - contraction 2* sens to ACh
- bulbar muscle weakness = asp
3. TIVA > VA (VA ok, vs dmd)
4. Simple analgesia + TAP block
5. SUGA
6. ? ICU/ETT - delay wean
7. Warm
OBSTETRICS – PLACENTA PRAEVIA
[08A7] 34yo F 36/40 known anterior placenta praevia, LSCS is scheduled. No other health problems. Previous Hx of 2x LSCS under regional. Describe & justify the changes this Hx would make to your routine pre-op + intra-op management plans for CS.
Preop
- ID disaster
- Focused Hx
- Routine Ex
- Ix
* Consult x5
- obs/neo/icu/IR/haem
- Optimise x3
- X match 2U presnet
- Cell save
- Daytime + 2nd anaes
- Consent/explain
- GA vs RA
Intraop
- 2x14G + fluid warmer
- CSE if reigonal
- bleeding –> GA
- oxytocics
- IAL
- BIS
- RSI ETT
- TIVA to dec uterine atony
- vigilace re bleeding - 40-50% blood loss prior drop bp
OBS and Cardiac
AS
MS
MR/AR
Mech valve
PHTN/RV dys
AS
1. Gentle neuraxial
2. Vasoplegia mx
3. Rx haem with volume resus
MS
PHTN**
PVR!!
- red via: 1. milrinon, NO, PC, sildenafil, avoid hi CO2
Oxytocic
Oxytocin 0.5-1U bolus
CI ergo/carboprost - inc Ppulm
Blue Book 2023
