O&G Flashcards
OBSTETRICS - IUFD
[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:
1. Ante: malf, inf, APH, PET, DM
MIA / PD
- Intra: abruption, infection, prolapse, rupture
Placental
Cord
Infection
Uterus
PICU
- 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
(59.1%) An unfortunately not uncommon scenario facing those who work in maternity care.
It is a distressing time for the patient, family, and the staff involved.
There were some high scoring answers to this question demonstrating candidates had been involved in the management of patients with a diagnosis of IUFD and were able to comprehensively discuss all the relevant issues.
An answer was required to consider the welfare issues and the multidisciplinary approach to patient management and most candidates did demonstrate they understood the importance of this.
Consideration of the causes and timing of the fetal demise and the possibility of sepsis and coagulopathy was also required.
These important issues were sometimes missed, and this led to an incomplete discussion of analgesic and anaesthetic options for delivery.
OBSTETRICS – AMNIOTIC FLUID EMBOLISM
[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/other
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*
AFE MX
** immediate = supportive**
EMST
A-E
ALSO
1. SUPRADIAPHRAGMATIC IV
2. Left uterine displ
3. Higher chest comp
4. Early ETT
5. Resus hysterotomy (out in 5)
Post care (always after crises):
ICU
Debried
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 20/40
PET: PIH + end organ
- Renal - proteinruria
- Haem - thrombo/haemolysis/DIC
- Liver - Raised transaminases
- Neuro - headache/hyperreflexia/clonus
- Pulm - APO
- Fetal - FGR
RHL NPF
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
QCG - hypertension and preg
NSW FEx course
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.
obs PDPH
PDPH
Inc: 0.2-1%
60-90% post epidural DP
Compl
1. SDH
2. Seziures
3. Sagittal sinus thrombosis
3S
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
Mx strategies
1. Conserve
- regular simple analgesia (level B)
2. **EBP **
Risks (level A - nysora)
- repeat DP
- backache
- neurological compli
3. Prophylactic
4. F/U monitoring
JAMA consensus 2023
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2808365
https://www.nysora.com/education-news/prevention-diagnosis-and-management-of-post-dural-puncture-headache/
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.
Obs APH
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
Maintanence
- VA –> TIVA (if atony)
- ?cell salvage
- MTP - rmb Ca++
- hysterectomy PRN
Post
- HDU/ICU
- continue uterotoni
Key (surg/resus/coag)
1. Surgical control
2. Resus
3. Correct coag +/- TXA
- triad- acid/coag/hypotherm
(59.9%) The borderline answer should include assessment of mother and foetus to determine degree of urgency.
Consideration of need to involve others-blood bank, operating room, obstetrician.
There should be a clear plan for
cardiovascular resuscitation/instability
considering
transfusion management,
aortocaval compression.
Mention of rapid sequence induction with clear plan for difficult airway.
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%)
Obs PPH
- The potential Obstetric and non-obstetric causes of collapse
Obs
1. PPH = 4T
tone > trauma > tissue > thrombin
2, AFE
VSLHH
vasovagal
spinal
LAST
HH
HEALO
Non-obs
1. PE/ICH/MI/BGL
- Investigations consistent with PPH.
Hx - TTTT
Ex - CVS/Resp/CNS
Ix - ECG/FBC/coag/abs
+
Emergency - no time
Physio changes of preg
Unfasted
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 rff. aspiration risk) / ketamine
(71.5%) Candidates were expected to mention the following
- The potential Obstetric and non-obstetric causes of collapse
- History,examination and investigations consistent with PPH.
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
[2022] You are asked to review a 32-year-old G1P1 woman complaining of right leg weakness the day after an instrumental vaginal birth of a 4.2 kg baby under epidural analgesia.
Describe your assessment of the patient and management of the likely differential diagnoses. Pass rate 80.7%
[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%)
Hx/Ex/Ix
DDx
Obs vs Anaes
Obs - mononeuropathy
An - radiculopathy
Pass rate 80.7%
This question had an excellent pass rate which may reflect widespread experience of this aspect of obstetric anaesthetic practice.
The first part of the question was very well answered by most candidates with the better answers then going on to describe a number of differential diagnoses and plans for their management.
Candidates were required to consider the following:
* patient history - elucidating relevant red flags
* patient examination involving neurological assessment
* relevant investigations
* at least birth/forceps related injury and epidural related injury as differential diagnoses
* management, documentation, and referral where appropriate.
P847 OHA
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.
MD - think weak muscles
pharyngeal muscle weak = asp + OSA
MD (DM1 / DM2)
1. Resp
- diaphragm weak
- aw muscle weak
–> risk of asp
- cardiac - CM/rate
- GI - hypom
–> aspiration - Uterine atony Ix
- Insulin resistance, hypothyroidism, adrenal insuff, MVP
- ECHO - MVP (20%)
- RFTs - RLD (spiro) / OSA (sleep study)
Labour > GA Reasons:
1. Asp
2. Sens to opioids
3. No sux (contraction/rhabdo), no neo (contraction 2o sens to ACh)
Labour plan
1. Early epi
2. Pacing if conduction def
3. Fundal ?provoke myotonia
Periop
- epi top-up
If GA
1. Premed - prokin/rani
2. RSI - prop/roc/alf
- sux = rhabdo
- antiACh - contraction 2o 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
(52.4%) The following were key components of an answer required to pass this question:
- A demonstration of understanding of myotonic dystrophy and its potential subclinical problems relevant to this pt, such as:
Respiratory impairment due to diaphragmatic weakness and expiratory muscle weakness
Airway muscle weakness, increasing the risk of aspiration
Cardiac abnormalities such as cardiomyopathy and arrhythmias
Gastrointestinal abnormalities such as hypomotility, again increasing the risk of aspiration
- A sensible list of investigations to be performed with an explanation as to what is being looked for (eg looking for cardiomyopathy and mitral valve prolapse if echocardiography is recommended)
- Early epidural analgesia for labour is recommended given the risks with opioids, nitrous oxide and other sedatives
- Monitoring during labour (oximetry, cardiotocography) should be described
- An appreciation of the increased risk of bleeding post partum in this patient, and how to plan for this (eg additional IV access, ensuring
cross matching has been performed etc) - Avoiding complications relating to the management during Caesarean section, in particular
o The difficulties with the use of muscle relaxants, especially suxamethonium o Increased aspiration risk
o Increased sensitivity to sedative/hypnotics
o Myotonic responses from mechanical/electrical stimulation
A postoperative plan for analgesia that avoids sedatives, and for postoperative monitoring eg in a high dependency area - Comments about how this question was answered:
o Good candidates mentioned other aspects of myotonic dystrophy, such as insulin resistance, hypothyroidism, adrenal insufficiency and mitral valve prolapse
o Good candidates were also able to balance the potential complications from both regional and general anaesthesia techniques for Caesarean section
o Poor answers gave a brief description of a management plan with little or no justification included.
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.
Praevia - placenta b/w fetus AND cervical os
1/200
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
[23A06] Discuss the implications of anticoagulation as well as an appropriate anticoagulant management strategy for a 25-year-old with a mechanical aortic valve for the duration of pregnancy, delivery and the postpartum period. Pass Rate 43.9%
Implications – State the Facts
* Warfarin Embryopathy (5-7%, and safe < 5mg in T1)
–> mid-face hypoplasia
* Clexane – transition, dosing, monitoring (anti FXa level)
* Heparin
* Risks of bleeding and thrombosis, foetal loss, death
During Pregnancy –
Clexane in 1st trimester warfarin 2nd until 36?
Leading up to delivery
* Admit – transition to UFH, or just stop clexane?
* Timing of stopping – 4-6 hours pre delivery (5cms) * Significance for Regional - PLAN
* Influence of IOL vs El LSCS
NSW Obs lecture
Pass Rate 43.9%
This question required candidates to demonstrate an adequate understanding of anticoagulation principles for a mechanical valve prosthesis and
extrapolate these principles and their implications to gestation and the peripartum period.
The discussion requirements for a pass to this question were as follows:
- Continuation of anticoagulation up until close to delivery
- Potential effects of anticoagulation on the fetus, including teratogenicity
and fetal loss risks due to haemorrhage - Implications for neuraxial techniques
- Risk of major bleeding
There were many who overlooked key components to the question and focused on only one or two facets of the question, which was inadequate to gain a pass.
Some candidates appeared to have been short of time given the brevity of some of the answers.
Better answers also included a discussion that these are high risk pregnancies, with death and thromboembolic complications possible in the mother, and
the place of other therapeutic options pre- and post-delivery such as low molecular weight heparin.
Fontan with PHTN
Epidural
Synto
Early hysterectomy
well FONTAN = WHO III
FONTAN + compl = WHO IV
Compli
1. Sat < 85%
2. Arrhythmia
3. Enteropathy
PAH = WHO IV itself
