Obstetric CRQs

Dani is a 32-year-old woman who is 26 weeks pregnant and is found to have a blood pressure
(BP) of 160/104 mmHg in antenatal clinic. Her booking BP was 122/74 mmHg. Her urine
dipstick is negative for protein, and she is diagnosed with gestational hypertension.
a) List four diagnostic criteria for gestational hypertension. (4 marks)
1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
4. ___________________________________________________________________
Dani is admitted to the ward for BP control and commenced on oral labetalol. A history of
hypertension in a previous pregnancy means she is at high risk of pre-eclampsia, and she is
commenced on aspirin.
b) State three other medical conditions which increase a woman’s risk of developing
pre-eclampsia. (3 marks)
1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
Dani’s BP is managed with oral labetalol and preparations are made to discharge her home.
She is advised to seek immediate advice if she experiences symptoms of pre-eclampsia.
c) List four common symptoms of pre-eclampsia. (4 marks)
1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
4. ___________________________________________________________________
On a subsequent admission, Dani is found to have a BP of 157/110 mmHg with significant
proteinuria, and a diagnosis of pre-eclampsia is made.

d) What is the definition of significant proteinuria? (1 mark)

______________________________________________________________________
e) List three biochemical or haematological abnormalities that may be found in patients
with severe pre-eclampsia. (3 marks)
1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
f) Oral labetalol fails to control her BP adequately. Name two parenteral drugs with doses
which are used primarily to control blood pressure in severe pre-eclampsia. (2 marks)
1. ___________________________________________________________________
2. ___________________________________________________________________
Dani continues to deteriorate despite medical management. Preparations are being made to
deliver the foetus when Dani suddenly loses consciousness and has a tonic-clonic seizure.
g) State the drug that should be given, including the initial dose, maintenance dose and
duration. (3 marks)
Drug: _________________________________________________________________
Initial dose: ____________________________________________________________
Maintenance dose/duration: _______________________________________________

Siobhan presents to the Emergency Department with a short history of painless vaginal
bleeding. She is 38 weeks pregnant and is visiting family in England. She remembers being
told about a low-lying placenta but has been unable to attend any follow-up antenatal
clinics.
a) Describe the four grades of placenta praevia by their relationship to the internal cervical
os. (4 marks)
Grade 1:_______________________________________________________________
Grade 2:_______________________________________________________________
Grade 3:_______________________________________________________________
Grade 4:_______________________________________________________________
b) Aside from a low-lying placenta, list five risk factors for placenta praevia. (5 marks)
1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
4. ___________________________________________________________________
5. ___________________________________________________________________
Following ultrasonography, Siobhan is told that her placenta is anterior and in a position
that rules out normal vaginal delivery. Her observations are normal and her symptoms have
now subsided. A decision is made to perform a caesarean section.

c) How may your anaesthetic differ for this procedure when compared to that of a low-risk
elective caesarean section? (7 marks)
1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
4. ___________________________________________________________________
5. ___________________________________________________________________
6. ___________________________________________________________________
7. ___________________________________________________________________
Abnormal placental adherence describes the degree to which there is an invasion of
chorionic villi into the myometrium because of a defect in the decidua basalis.
d) List the three forms of abnormal placental adherence (3 marks) in order of increasing
incidence. (1 mark)
Least common:__________________________________________________________
Intermediate:___________________________________________________________
Most common:____________________________________________________
Victoria is due to undergo a caesarean section after failing to progress in the second stage of
labour. An epidural was sited by your colleague earlier in the day and has been working well.
Following assessment of the patient, you decide to top up the epidural in theatre with
standard monitoring.
a) Apart from using a safe dose, list four steps that you can take to reduce the risk of local
anaesthetic (LA) toxicity during performance of the block. (4 marks)
1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
4. ___________________________________________________________________
b) Explain, with reference to pharmacokinetics, why pregnant patients are at an increased
risk of LA toxicity. (3 marks)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
c) In the table below, outline the maximum doses of the local anaesthetic agents shown.
(4 marks)

Table 6.8c Maximum doses of local anaesthetic agents

Local anaesthetic
Maximum dose without
adrenaline (mg/kg) and with adrenaline:

Lignocaine
Bupivacaine
Ropivacaine
Prilocaine N/A

d) List four patient-related risk factors for LA toxicity in non-obstetric patients. (4 marks)
1. ___________________________________________________________________
2. ___________________________________________________________________

3. ___________________________________________________________________
4. ___________________________________________________________________
Intravenous lipid emulsion (Intralipid®) should be administered as part of the management
of LA-induced cardiac arrest.
e) Outline the details of the regimen that should be used for a 70 kg female as described
below. (4 marks)
Concentration of lipid emulsion (%): ________________________________________
Bolus dose (mL):________________________________________________________
Initial infusion rate (mL/h):________________________________________________
Maximum cumulative dose (mL):___________________________________________
f) State an additional consideration regarding the duration of cardiopulmonary resuscita-
tion in a patient with LA-induced cardiac arrest. (1 mark)
___________________________________________________

Hazra is a 34-year-old primigravida who is 38 weeks pregnant. She presents to the maternity
unit with a 1-week history of increasing shortness of breath, ankle swelling and fatigue.
a) Which three criteria must be met to make a diagnosis of peripartum cardiomyopathy
(PPCM)? (3 marks)
1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
b) List three changes you may see on an ECG in a normal pregnancy. (3 marks)
1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
c) List five risk factors for PPCM. (5 marks)
1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
4. ___________________________________________________________________
5. ___________________________________________________________________
Hazra undergoes a caesarean section under combined spinal–epidural anaesthesia.
d) List five principles of intra-operative management in this case. (5 marks)
1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
4. ___________________________________________________________________
5. ___________________________________________________________________
e) For each of the following uterotonics, state two deleterious effects that may occur in
patients with PPCM. (4 marks)
Oxytocin:
1. ___________________________________________________________________
2. ___________________________________________________________________
Ergometrine:
1. ___________________________________________________________________
2. ______________________________________________________________