Obstetrics Flashcards
Postdural puncture headache in obstetric anaesthesia is associated with a greater likelihood of all of the following EXCEPT:
a) Sheehan’s
b) Cortical vein thrombosis
c) Bacterial meningitis
PREVIOSU ANSWERS:
a) Postpartum depression
b) Bacterial meningitis
c) Chronic back pain
d) Cerebral vein thrombosis
e) Posterior reversible encephalopathy syndrome (PRES)
repeat: Sheehans
sheehans not an option previously
- It was in 2019.1 sorry!
previous question answers
Encephalitis most likely answer
https://www.uptodate.com/contents/post-dural-puncture-headache
Complications of PDPH
1. Chronic Back pain
2. Hearing loss
3. Acute onset headache consider pneumopcephalus headache
4. Persistent headache
5. Increased risk of subdural haematoma
6. postpartum depression
7. bacterial meningitis
8. Reversible cerebral vasoconstriction syndrome (RCVS)
9. Posterior reversible encephalopathy syndrome (PRES)
Cyclooxygenase-2 (COX-2) inhibitors in pregnancy are considered:
a) Not safe
b) Safe
c) Safe only in 3rd trimester
d) Safe after 1st trimester up to 48hrs prior to delivery
REPEAT with slightly reworded answers
A is safest answer.
Previous iterations of this Q have been controversial. NSAIDs technically safe in first trimester, but not in third (post 32 weeks) as can cause premature duct closure.
a. Not safe
or
safe only in 1st trimester
While relatively safe in early and mid pregnancy, NSAIDs can precipitate fetal cardiac and renal complications in late pregnancy, as well as interfere with fetal brain development and the production of amniotic fluid; they should be discontinued in gestational wk 32
APMSE
A healthy woman is admitted to the obstetric unit with threatened preterm labour at 29 weeks gestation. Her blood pressure is 140/80 mmHg. A magnesium sulfate infusion is indicated for the purpose of:
a) Foetal neuroprotection
b) Treat BP
c) eclampsia prevention
d) Tocolysis
LINDON A - Foetal neuroprotection
https://www.kemh.health.wa.gov.au/~/media/HSPs/NMHS/Hospitals/WNHS/Documents/Clinical-guidelines/Obs-Gyn-Guidelines/Preterm-Labour-Magnesium-Sulphate-for-Neuroprotection-of-the-Fetus.pdf?thn=0#:~:text=MgSO4%20is%20only%20given%20to,4%20hours%20prior%20to%20delivery.
The commonest symptom or sign of uterine rupture during attempted vaginal birth after caesarean is:
a) Pain between contractions
b) CTG persistent foetal bradycardia
c) Variable decels on CTG
d) PV Bleeding
LINDON Fetal bradycardia
No idea - commonest sign is pv bleeding and fetal brady (non specific) and both answers are there!
Mentioned on MELB course that foetal Brady
A patient experiences a postpartum haemorrhage associated with uterine atony that is unresponsive to oxytocin and ergometrine. The recommended intramuscular dose of carboprost (15-methyl prostaglandin F2 alpha) to be administered is:
a) 250mcg IM once
b) 250mcg IM q15mins, up to 2mg
c) 500mcg IM
d) 250mcg IV
e) 500mcg IV
REPEAT
b) 250mcg IM q15mins, up to 2mg
15-methyl-PGF2α (carboprost; Prostinfenem) which may be administered in one of two ways:
Intra-muscular injection of 0.25mg, in repeated doses as required at intervals of not less than 15 minutes to a maximum total cumulative dose of 2.0mg (ie up to 8 doses)
Source RANZCOG PPH Guideline 2021
21.2 The main advantage of using noradrenaline (norepinephrine) over phenylephrine for the prevention of hypotension as a result of spinal anaesthesia for elective caesarean section is
a) Better APGAR
b) Better foetal acid-base balance
c) Less nausea & vomiting
d) Less maternal bradycardia
less bradycardia
21.1, 20.1 The coagulopathy that can result from intrahepatic cholestasis of pregnancy is due to
a. 2/7/9/10
b. All clotting factors made by the liver
c. Thrombocytopenia
d. Platelet dysfunction
e. Fibrinolysis
a. 2/7/9/10
Hypovitaminosis of Vitamin K
(Bile required for absorption)
Source: BMC Article
https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-022-04875-w
22.1 The most common cause of maternal mortality in women with preeclampsia is
a. Renal failure
b. Hepatic failure
c. Intracranial haemorrhage
Intracranial haemorrhage
AHA
https://www.ahajournals.org/doi/epub/10.1161/HYPERTENSIONAHA.118.11513
23.1 A healthy woman is admitted to the obstetric unit with threatened preterm labour at 29 weeks gestation. Her blood pressure is 140/80 mmHg. A magnesium sulfate infusion is indicated for the purpose of
A. Maternal seizure prevention
B. Fetal lung development
C. Foetal neuroprotection
C. Foetal neuroprotection
https://www.kemh.health.wa.gov.au/~/media/HSPs/NMHS/Hospitals/WNHS/Documents/Clinical-guidelines/Obs-Gyn-Guidelines/Preterm-Labour-Magnesium-Sulphate-for-Neuroprotection-of-the-Fetus.pdf?thn=0#:~:text=MgSO4%20is%20only%20given%20to,4%20hours%20prior%20to%20delivery.
21.1 A normal 75 kg term parturient may be expected to have a total blood volume of
a. 5250
b. 6000
c. 6750
d. 7500
d. 7500
100ml/kg blood volume in term parturient
7.5L (Average increase around 48%)
BJAed
21.1, 21.2 In maternal cardiac arrest the most common arrhythmia is
a) PEA
b) VT
c) VF
d) Asystole
e) SVT
a) PEA
I couldn’t find a great article on this anywhere. BJAED hasn’t got much either
23.1 In subarachnoid block for caesarean section, hyperbaric local anaesthetic compared to regular local anaesthetic has been shown to reduce the
a. Risk of total spinal
b. Analgesic properties
c. Onset of anaesthetic
d. Offset of anaesthetic
e. Chance of inadequate anaesthetic
reduce onset time
c) faster onset of anaesthetic
https://pubmed.ncbi.nlm.nih.gov/28708665/ agrees with faster onset but for non obstetric surgery
UTD
hyperbaric bupivacaine because of its rapid onset and the option to modify the spinal level by changing the position of the operating table. Plain bupivacaine (ie, slightly hypobaric, prepared in saline) may also be used for spinal anesthesia for CD. The literature comparing safety and efficacy of hyperbaric with isobaric bupivacaine for CD is inconclusive
22.1 A 30-year-old parturient presents in labour. She has a history of Addison’s disease from autoimmune adrenalitis and has been taking prednisolone 6 mg daily for ten years. On presentation the patient is given hydrocortisone 100 mg intravenously. The most appropriate steroid replacement regimen the patient should receive during labour is
a. 25mg TDS hydrocortisone
b. 8mg/hr hydrocortisone
c. 6mg PO prednisone
8mg/hr
Guidelines for mx of glucocorticoids during the perioperative period for patients with adrenal insufficiency
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.14963
21.1 The main advantage of using norepinephrine (noradrenaline) over phenylephrine for the prevention of
hypotension as a result of spinal anaesthesia for elective caesarean section is
A. Better APGAR
B. Better foetal acid/base
C. Less nausea/vomiting
D. Less maternal bradycardia
less maternal bradycardia
21.1 A 30-year-old woman, gravida 2, parity 1, undergoes an elective lower segment caesarean section for breech presentation. The international consensus statement on the use of uterotonic agents recommends that the first line uterotonic management is
a) 1unit
b) 1 unit followed by infusion 2.5-7.5 Units/hr
c) 3 units
d) 3 units followed by infusion
Bolus 1 IU oxytocin; start oxytocin infusion at 2.5–7.5IU.h (0.04–0.125 IU.min)
EmLSCS; 3 IU oxytocinover≥30 s; start oxytocininfusion at 7.5–15 IU.h (0.125–0.25 IU.min).
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.14757
23.1 According to the categorisation system used in Australia and New Zealand for prescribing medicines safely in pregnancy, category X denotes drugs which are
a. Drugs that absolutely must not be used for pregnancy. (absolute contraindication)
b. Untested drugs in pregnancy
c. Drugs safe in pregnancy
a. Drugs that absolutely must not be used for pregnancy. (absolute contraindication)
https://www.tga.gov.au/australian-categorisation-system-prescribing-medicines-pregnancy
20.1 What is the level below which we need to replace fibrinogen in a pregnant patient with a PPH
A. <1 g/L
B. <1.5 g/L
C. <2 g/L
D. <2.5 g/L
E. <3 g/L
<2g/L
23.1 For a woman who has a history of preeclampsia in a previous pregnancy, the intervention with the best evidence for prevention of preeclampsia during future pregnancies is
A. Aspirin 150mg daily (option was definitely 150mg not 100mg)
B. Mg
C. Heparin subcut
D. Ca
A. Aspirin 150mg daily (option was definitely 150mg not 100mg)
or
D. Ca
Aspirin should be given at a dose between 75 and 150 mg per day, started preferably before 16 weeks, possibly taken at night, and continued until delivery;
https://www.somanz.org/content/uploads/2023/06/SOMANZ_Hypertension_in_Pregnancy_Guideline_2023.pdf
Calcium supplementation (1.5g/day) should therefore be offered to women with moderate to high risk of preeclampsia, particularly those with a low dietary calcium intake (247)
22.2 Which of the following risk factors for preeclampsia in isolation would be sufficient to recommend commencing low-dose aspirin?
a. Age >40
b. >10 years since last pregnancy
c. Family hx of pre eclampsia
d. autoimmune disease
e. BMI >35
d. autoimmune disease (with potential vascular complications)
RANZCOG
Maternal characteristics that are associated with an increased likelihood of pre-eclampsia include:
- previous pre-eclampsia, particularly when more serious or early onset before 34 weeks
- pre-existing medical conditions (including chronic hypertension, underlying renal disease, or pre-gestational diabetes mellitus),
- underlying antiphospholipid antibody syndrome,
- multiple pregnancy
UTD: Preeclampsia: Prevention
https://www.uptodate.com/contents/preeclampsia-prevention
Based on the available data (see ‘Evidence of efficacy’ above), we recommend low-dose aspirin prophylaxis for women at high risk for preeclampsia. There is no consensus on the exact criteria that confer high risk. It is reasonable to use the US Preventive Services Task Force (USPSTF) high-risk criteria, which are also endorsed by the American College of Obstetricians and Gynecologists (ACOG).
The incidence of preeclampsia is estimated to be at least 8 percent for pregnant women with any one of these high risk factors:
●Previous pregnancy with preeclampsia, especially early onset and with an adverse outcome
●Multifetal gestation
●Chronic hypertension
●Type 1 or 2 diabetes mellitus
●Chronic kidney disease
●Autoimmune disease with potential vascular complications (antiphospholipid syndrome, systemic lupus erythematosus)
22.2 An analgesic which is a category A drug using the Australian and New Zealand categories for prescribing medicines in pregnancy is
a. codeine
b. morphine
c. fentanyl
d. tramadol
e. oxycodone
a. codeine
Oxycodone B
Morphine C
Tramadol C
Fentanyl C
20.1 A woman who is 35 weeks pregnant presents with nausea and vomiting. Among other blood test abnormalities, her alanine transaminase (ALT) level is 400 IU/l (normal <34) and her International Normalized Ratio (INR) is 2.3. This is most consistent with
a) Hyperemesis gravidarum
b) HELLP syndrome
c) PET with severe features
d) Intrahepatic cholestasis of pregnancy
e) Acute fatty liver of pregnancy
a) Acute fatty liver
Key differences between AFLP and HELLP
- Coagulopathy with deranged INR in AFLP Vs. Thrombocytopenia in HELLP
- Thrombocytopaenia in HELLP, Plts tend to be unaffected in AFLP
- Degree of transaminitis in stem consistent with aFLP
Swansea Criteria for AFLP: Atleast 6 or more of the features described:
- Vomiting
- Abdominal pain
- Polydypsia/polyuria
- Encephalopathy
- Elevated Bilirubin
- Hypoglycaemia
- Elevated urate
- Leucocytosis
- Ascites/ Bright liver on US scan
- Elevated transaminases
- Elevated Amonia
- Renal impairment
- Coagulopathy
- Microvesicular streatosis on liver biopsy
AFLP:
Pathophysiology
- Variant of pre-eclampsia
- presents in the late 3rd trimester
- more common in women with multiple pregnancies and lower BMI
- Women with the condition are more likely to have children with disorders of B-fatty oxidation
- Associated with high maternal mortality, on average 1 death per year
Daignosis and presentation:
- Diagnosis by Swansea criteria in absence of another explanation
- Imaging with CT or MRI a liver biopsy or fat stain may support diagnosis
- present with non-specific symptoms of:
Nausea and vomiting
Malaise
Associated Htn and proteinuria
- Renal impairment develops in 90% of patients
- Fulminant hepatic failure can occur
- Patients may develop hepatic encephalopathy, coagulopathy and profound hypoglycaemia
- Metabolic acidosis and elevated lactate are not part of diagnostic criteria but are important features
- Pancreatitis and ARDS are other rare complications
Delivery and Anaesthetic concerns:
- Delivery must be expedited once the patient is stablized due to high foetal mortality
- Specific anaesthetic concerns are top correct hypoglycaemia and coagulopathy before delivery
- Plt function tends to remain stable unlike HELLP syndrome
- Uneventful regional anaesthesia has been reported and may improve hepatic blood flow but is often precluded due to coagulopathy
- Symptoms can deteriorate post-partum with worsening liver, renal function and coagulopathy for 48hrs
20.2 A preeclamptic woman presents with a blood pressure of 150/100 mmHg. An appropriate first line treatment to reduce the blood pressure is
a. Labetalol
b. Nifedipine
c. Magnesium
d. Methyldopa
e. Perindopril
Labetalol
RANZCOG
first line drugs are
> methyldopa
> labetalol
> oxprenolol.
Second line agents are:
- hydralazine
- nifedipine
- prazosin.
Acute Rx:
Labetalol: 20-40mg IV q10min
Nifedipine 10-20mg PO Q45min
Hydralazine 5-10mg IV q20min
20.1 Epidural filters are designed to retain particles down to a diameter of
A. 20 nanometers
B. 200 nanometers
C. 2 micrometers
D. 20 micrometers
E. 200micrometers
B. 200 nanometers (0.2 micrometres)
20.1 Of the following, the maternal cardiac condition that represents the highest risk of mortality associated with pregnancy is
a. Bicuspid aortic valve with significantly dilated aortic root
b. Fontan circulation
c. HOCM
d. PDA
A - Modified WHO class 4
B - Modified WHO class 3 (4 if ANY complication)
C - Modified WHO class 2-3 (if severe AS - 4)
D - Modified WHO class 1
Class 4 = 40-100% risk of event
Source
https://academic.oup.com/eurheartj/article/39/34/3165/5078465
Table:
https://academic.oup.com/view-large/186437995
20.1 A postpartum woman presents with numbness over the anterior thigh, and weakness on flexion of the hip and extension of the knee. An epidural was sited for labour and she underwent an instrumental delivery. The most likely site of the injury is the:
a) Femoral nerve
b) Lateral femoral cutaneous nerve
c) Lumbosacral plexus
d) Obturator nerve
e) Sciatic nerve
a) Femoral nerve
Nerve roots: L2-L4
Motor functions: Innervates the anterior thigh muscles that flex the hip joint (pectineus, iliacus, sartorius) and extend the knee (quadriceps femoris: rectus femoris, vastus lateralis, vastus medialis and vastus intermedius),
Sensory functions: Supplies cutaneous branches to the anteromedial thigh (anterior cutaneous branches of the femoral nerve) and the medial side of the leg and foot (saphenous nerve).
The needle whose tip is pictured is a
a) Sprotte
b) Quinke
c) Touhy
d) Whitacre
c) Touhy
