Maternal Comorbidities — MCQs
The first step on priority basis required in the management of status epilepticus is
Anesthesia of choice for cesarean section in severe preeclampsia:-
The diagnosis of diabetes mellitus is certain in which of the following situations?
What is the management of eclampsia at 34 weeks of pregnancy?
All are cardiovascular system changes in pregnancy except.
A female presents with placenta previa with active bleeding and blood pressure of 80/50 mm Hg and pulse rate of 140 bpm. The choice of anaesthesia for emergency cesarean section in this female is?
The Anaesthesia technique of choice in severely preeclamptic women for cesarean delivery -
In Peripartum cardiomyopathy, cardiac failure occurs at:-
Most common cause of maternal mortality in spinal anesthesia is ?
Which is not true about spinal anesthesia?
Maternal Comorbidities Indian Medical PG Practice Questions and MCQs
Question 1: The first step on priority basis required in the management of status epilepticus is
- A. i.v. Phenytoin
- B. i.v. Phenobarbitone
- C. Airway maintenance (Correct Answer)
- D. i.v. Diazepam
Explanation: ***Airway maintenance*** - Maintaining a **patent airway** is the absolute first step in any emergency, especially in status epilepticus where respiratory depression and aspiration risk are high [2]. - Ensuring adequate **oxygenation and ventilation** is critical for preventing brain hypoxia and further complications [1]. *i.v. Phenytoin* - While an important drug for the long-term management and prevention of recurrent seizures, **phenytoin** has a delayed onset of action and is not the first-line agent for acute seizure termination in status epilepticus. - It is typically administered after initial first-line agents like benzodiazepines have been given. *i.v. Phenobarbitone* - **Phenobarbitone** is a potent anticonvulsant and can be used in refractory status epilepticus, but it is not the very first step. - Its use often comes with significant **sedation and respiratory depression**, necessitating close airway monitoring. *i.v. Diazepam* - **Intravenous diazepam** is a rapid-acting benzodiazepine and is usually the first-line medication to **terminate acute seizures** in status epilepticus. - However, airway maintenance precedes even medication administration to ensure patient safety before drug effects take hold [1], [2].
Question 2: Anesthesia of choice for cesarean section in severe preeclampsia:-
- A. Spinal (Correct Answer)
- B. GA
- C. Epidural
- D. Combined spinal-epidural (CSE)
Explanation: ***Spinal*** - **Spinal anesthesia** is generally preferred in severe preeclampsia because it provides **rapid onset** of dense block, which can be critical for emergent cesarean sections. - It avoids the risks associated with general anesthesia in these patients, such as difficult intubation and exaggerated **hypertensive response** to laryngoscopy. *GA* - **General anesthesia (GA)** in severe preeclampsia carries increased risks due to **airway edema**, potential for difficult intubation, and significant **blood pressure fluctuations** during induction and intubation. - It can exacerbate the already compromised uteroplacental perfusion due to the sympathetic blockade and the potential for a **hypotensive episode**. *Epidural* - While generally safe in less severe preeclampsia, an **epidural** has a **slower onset** compared to spinal anesthesia, which may be a disadvantage in emergent situations. - The gradual sympathetic blockade with an epidural is often preferred to avoid sudden drops in blood pressure, but the delay in achieving a surgical block might not be acceptable in severe, unstable cases. *Combined spinal-epidural (CSE)* - **Combined spinal-epidural (CSE)** offers the rapid onset of a spinal block with the flexibility of an epidural catheter for prolonged anesthesia or postoperative pain control. - However, in cases of severe preeclampsia where **hemodynamic instability** is a major concern, the relatively larger dose of local anesthetic required for epidural component can lead to a more pronounced or rapid drop in blood pressure.
Question 3: The diagnosis of diabetes mellitus is certain in which of the following situations?
- A. Abnormal oral glucose tolerance in a 24-yrs-old woman who has been dieting
- B. A serum glucose level >7.8 mmol/L in a woman in her twenty-fifth week of gestation after a 50-g oral glucose load
- C. Persistent asymptomatic glycosuria in a 30-yrs-old woman
- D. Successive fasting plasma glucose concentrations of 8, 9, and 8.5 mmol/L in an asymptomatic, otherwise healthy individual. (Correct Answer)
Explanation: ***Successive fasting plasma glucose concentrations of 8, 9, and 8.5 mmol/L in an asymptomatic, otherwise healthy individual.*** - A definitive diagnosis of **diabetes mellitus** requires two separate fasting plasma glucose (FPG) levels of **≥7.0 mmol/L** (126 mg/dL) or higher [1]. The given values (8, 9, 8.5 mmol/L) meet this criterion. - Since the individual is **asymptomatic**, two abnormal tests are typically needed to confirm the diagnosis, which is satisfied by the successive elevated fasting glucose levels. *Abnormal oral glucose tolerance in a 24-yrs-old woman who has been dieting* - **Dieting** can affect glucose metabolism and potentially lead to an abnormal oral glucose tolerance test (OGTT) result that does not accurately reflect diabetes. - A single abnormal OGTT in a dieting individual without confirmatory tests or symptoms is not sufficient for a definitive diagnosis of diabetes. *A serum glucose level >7.8 mmol/L in a woman in her twenty-fifth week of gestation after a 50-g oral glucose load* - A serum glucose level >7.8 mmol/L after a **50-g glucose challenge** is a positive screening test for **gestational diabetes mellitus**, but it is not diagnostic [2]. - A positive screening test requires further confirmation with a **100-g or 75-g oral glucose tolerance test** to diagnose gestational diabetes. *Persistent asymptomatic glycosuria in a 30-yrs-old woman* - **Glycosuria** (glucose in the urine) without hyperglycemia (elevated blood glucose) can be due to a low **renal threshold for glucose**, a benign condition called renal glycosuria. - While it warrants investigation for diabetes, persistent asymptomatic glycosuria alone is **not diagnostic** of diabetes unless accompanied by elevated blood glucose levels.
Question 4: What is the management of eclampsia at 34 weeks of pregnancy?
- A. Continue convulsions and wait for 37 weeks to complete.
- B. Wait for spontaneous labor.
- C. Continue blood pressure management.
- D. Administer antihypertensives, anticonvulsants, and consider termination of pregnancy. (Correct Answer)
Explanation: **Administer antihypertensives, anticonvulsants, and consider termination of pregnancy.** - In eclampsia, emergent management includes immediate administration of **magnesium sulfate** as an anticonvulsant and **antihypertensives** (e.g., labetalol, hydralazine, nifedipine) to control blood pressure. - Given the gestational age of 34 weeks and the occurrence of eclampsia, **delivery of the fetus** is often indicated to resolve the maternal condition, regardless of fetal lung maturity. *Continue convulsions and wait for 37 weeks to complete.* - Allowing **convulsions to continue** is extremely dangerous for both mother and fetus, increasing risks of aspiration, trauma, hypoxemia, and placental abruption. - Eclampsia is a severe complication of pregnancy that necessitates immediate intervention and **should not be passively observed** until full term. *Wait for spontaneous labor.* - **Delaying delivery** while waiting for spontaneous labor in eclampsia significantly prolongs the mother's exposure to the severe complications of the condition. - Eclampsia is an ** obstetric emergency** where prompt delivery, often via induction or C-section, is the definitive cure. *Continue blood pressure management.* - While **blood pressure management** is a crucial component of eclampsia treatment, it is insufficient on its own. - Eclampsia specifically involves **seizures**, which require anticonvulsant therapy (magnesium sulfate) in addition to antihypertensives, and the ultimate treatment is delivery.
Question 5: All are cardiovascular system changes in pregnancy except.
- A. Increase in blood volume
- B. Increase in heart rate
- C. Increase in peripheral resistance (Correct Answer)
- D. Increase in cardiac output
Explanation: ***Increase in peripheral resistance*** - During normal pregnancy, **peripheral vascular resistance actually decreases** due to the effects of hormones like progesterone and the presence of the low-resistance uteroplacental circulation. - This decrease in resistance helps accommodate the increased blood volume and cardiac output. *Increase in cardiac output* - **Cardiac output increases significantly** during pregnancy (by 30-50%) to meet the metabolic demands of the growing fetus and maternal tissues. - This is primarily achieved through an increase in both stroke volume and heart rate. *Increase in blood volume* - **Blood volume increases substantially** (by 30-50%) during pregnancy, with plasma volume increasing more than red blood cell mass. - This expansion supports the increased cardiac output and placental perfusion. *Increase in heart rate* - **Heart rate increases** during pregnancy, typically by 10-20 beats per minute, contributing to the overall increase in cardiac output. - This physiological adaptation helps maintain adequate circulation.
Question 6: A female presents with placenta previa with active bleeding and blood pressure of 80/50 mm Hg and pulse rate of 140 bpm. The choice of anaesthesia for emergency cesarean section in this female is?
- A. General anesthesia with intravenous propofol
- B. Spinal anesthesia
- C. General anesthesia with intravenous ketamine (Correct Answer)
- D. Epidural anesthesia
Explanation: ***General anesthesia with intravenous ketamine*** - **Ketamine** maintains sympathetic tone, supporting **blood pressure** in patients with significant **hemorrhage** and **hypovolemic shock**. - Its **bronchodilatory** properties are also beneficial, making it a suitable choice for this emergency scenario where the patient is **hemodynamically unstable**. *General anesthesia with intravenous propofol* - **Propofol** can cause significant **vasodilation** and myocardial depression, which would worsen the patient's existing **hypotension** and **tachycardia**. - Its use in an actively bleeding, **hemodynamically unstable** patient is generally contraindicated due to the risk of further **cardiovascular collapse**. *Spinal anesthesia* - **Spinal anesthesia** is contraindicated in patients with significant **hypovolemia** and **active bleeding** due to the risk of severe **hypotension**. - The sympathetic blockade caused by spinal anesthesia would exacerbate the patient's already compromised **hemodynamic status**, potentially leading to **cardiac arrest**. *Epidural anesthesia* - Similar to spinal anesthesia, **epidural anesthesia** causes **sympathetic blockade** and can lead to **hypotension**, making it unsuitable for a patient with **active bleeding** and **hypovolemic shock**. - The onset of **epidural blockade** is slower than spinal, but the hemodynamic effects are still detrimental in this critically ill patient.
Question 7: The Anaesthesia technique of choice in severely preeclamptic women for cesarean delivery -
- A. Spinal Anaesthesia (Correct Answer)
- B. General Anaesthesia
- C. Epidural Anaesthesia
- D. Pudendal block
Explanation: ***Spinal Anaesthesia*** - **Spinal anaesthesia** is generally preferred due to its rapid onset, excellent muscle relaxation, and better hemodynamic stability compared to general anaesthesia when careful fluid management is in place. - It avoids the risks associated with **difficult airway management** and aspiration in preeclamptic patients and minimizes fetal drug exposure. *General Anaesthesia* - **General anaesthesia** carries a higher risk of **rapid, unpredictable increases in blood pressure** during tracheal intubation and extubation, which can be dangerous in preeclampsia with an already compromised cardiovascular system. - It is associated with increased risks of **aspiration**, **difficult airway**, and **postoperative respiratory complications** in preeclamptic women. *Epidural Anaesthesia* - While generally safe, **epidural anaesthesia** has a slower onset compared to spinal anaesthesia, which may not be ideal in emergency situations requiring rapid delivery. - The titration of an epidural can be more challenging in patients with severe preeclampsia, where rapid changes in blood pressure need careful management. *Pudendal block* - A **pudendal block** provides local anaesthesia to the perineum, vulva, and lower vagina. - It is used for pain relief during vaginal delivery and is unsuitable for a **cesarean section**, which requires anaesthesia of the abdominal wall and uterus.
Question 8: In Peripartum cardiomyopathy, cardiac failure occurs at:-
- A. Within 24 months after delivery.
- B. Within 5 months after delivery. (Correct Answer)
- C. Within 6 weeks after delivery.
- D. Within 7 days after delivery.
Explanation: ***Within 5 months after delivery.*** - Peripartum cardiomyopathy (PPCM) is defined as the development of **cardiac failure** in the **last month of pregnancy** or within **5 months after delivery**, in the absence of any other identifiable cause. - Among the given options, "within 5 months after delivery" represents the **postpartum component** of the diagnostic timeframe and is the most complete answer. - This time frame is a key diagnostic criterion recognized by major cardiology societies (some recent guidelines extend this to 6 months postpartum). - **Note:** The complete definition includes both antepartum (last month of pregnancy) and postpartum (up to 5 months) periods. *Within 24 months after delivery.* - This timeframe is **too broad** and does not align with the standard diagnostic criteria for PPCM. - While some women may experience ongoing cardiac dysfunction or relapse, the initial diagnosis of PPCM is restricted to within 5 months postpartum. - Extended cardiac issues beyond 5 months may represent persistent PPCM or dilated cardiomyopathy rather than new-onset PPCM. *Within 6 weeks after delivery.* - While many cases of PPCM manifest within **6 weeks postpartum** (the traditional puerperium), this definition is **too restrictive**. - Symptoms can appear up to **5 months after delivery**, and using only 6 weeks would miss a significant proportion of cases. - This period captures the most acute presentations but doesn't encompass the entire recognized diagnostic window. *Within 7 days after delivery.* - The onset within **7 days after delivery** represents only the **immediate postpartum period** and is an overly narrow definition. - PPCM can develop much later in the postpartum period (up to 5 months), making this timeframe inadequate for diagnosis. - Using this restrictive criterion would result in many missed diagnoses.
Question 9: Most common cause of maternal mortality in spinal anesthesia is ?
- A. Allergy to local anesthesia
- B. Nerve injury
- C. Hypotension (Correct Answer)
- D. High block
Explanation: ***Hypotension*** - **Profound hypotension** due to sympathetic blockade is the most common cause of maternal mortality in spinal anesthesia. - This can lead to **decreased placental perfusion**, fetal distress, and maternal cardiovascular collapse if not promptly managed. *Allergy to local anesthesia* - True allergic reactions to local anesthetics are **extremely rare**, especially to ester-type anesthetics used in spinal anesthesia. - While possible, it is not the most common cause of maternal mortality. *Nerve injury* - **Direct nerve injury** during spinal anesthesia is a rare complication, usually resulting in localized neurological deficits rather than mortality. - It does not represent the primary cause of maternal death. *High block* - A **high spinal block** can cause severe hypotension and respiratory compromise, which can lead to mortality. - However, the underlying mechanism for the life-threatening aspects of a high block is often **severe hypotension** and subsequent cardiovascular collapse.
Question 10: Which is not true about spinal anesthesia?
- A. Useful for lower limb surgery
- B. It produces more hemodynamic alteration than epidural anesthesia
- C. Produces complete sensory and motor paralysis below the level (Correct Answer)
- D. Autonomic fibers are affected above the sensory level
Explanation: ***Produces complete sensory and motor paralysis below the level*** - While spinal anesthesia produces significant sensory and motor blockade, it is rarely a **complete paralysis** below the level of injection, especially in terms of all muscle groups and deep sensation. - The degree of blockade depends on the **dose of anesthetic**, the patient's individual anatomy, and the spread of the drug within the cerebrospinal fluid, leading to a variable rather than absolute "complete" paralysis. *Useful for lower limb surgery* - Spinal anesthesia is **highly effective** and commonly used for lower limb surgeries as it provides excellent surgical anesthesia and postoperative analgesia. - It targets the nerve roots innervating the lower extremities, successfully blocking sensation and motor function, which is ideal for procedures like **knee or hip replacements**. *It produces more hemodynamic alteration than epidural anesthesia* - Spinal anesthesia typically causes a more **rapid and profound sympathetic blockade** than epidural anesthesia, due to direct and rapid diffusion of local anesthetic into the cerebrospinal fluid (CSF). - This rapid blockade often leads to a more significant and faster decrease in **blood pressure and heart rate** due to widespread vasodilation and reduced venous return. *Autonomic fibers are affected above the sensory level* - Sympathetic (autonomic) fibers are typically smaller and unmyelinated, making them **more susceptible to local anesthetic blockade** than sensory or motor fibers. - Therefore, the **sympathetic blockade** often extends two to three dermatomes higher than the sensory block, resulting in vasodilation and potential hemodynamic changes in areas above the perceived sensory level.
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