Obstetric Anesthesia

Questions

DIRECTIONS (Questions 228-309): Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each case.

228. A parturient presents to labor and delivery complaining of decreased fetal movement at 34 weeks gestational age. The most likely next step to evaluate the well-being of the fetus is to perform a(n)

(A) oxytocin contraction test (OCT)

(B) biophysical profile (BPP)

(D) umbilical artery Doppler flow study

(E) fetal scalp pH analysis

229. You receive a page for an emergent cesarean section in a 27-year-old parturient in labor with a functioning epidural for fetal distress. You rush to the bedside, and after aspirating the epidural catheter, inject which one of the following agents or combination of agents while accompanying the patient to the operating room?

(A) 2% lidocaine with 1:200,000 epinephrine

(B) 3% 2-chloroprocaine

(D) 0.5% bupivacaine with bicarbonate

(E) 3% 2-chloroprocaine with sodium bicarbonate

230. Absolute contraindications to major conduction anesthesia in parturients include all of the following conditions EXCEPT

(A) preexisting neurologic disease of the spinal cord

(B) patient refusal

(D) hypovolemic shock

(E) severe coagulopathy

231. As compared with regional anesthesia for cesarean section, general anesthesia results in a/an/the

(A) approximately 17-fold increased risk of maternal death

(B) higher incidence of maternal hypotension

(D) majority of recent maternal deaths related to failed intubation rather than in the postoperative period

(E) lower incidence of uterine atony

232. A 30-year-old G1P1 patient underwent an emergent cesarean section under epidural anesthesia. She received 4 mg epidural morphine for pain control prior to removal of the catheter. Four hours postpartum she begins to complain of incisional pain. The most likely explanation for this is

(A) the dose of morphine is insufficient for epidural administration

(B) morphine has a high lipid solubility resulting in an expected analgesic period of 1-4 h

(D) 2% lidocaine with bicarbonate was used for the urgent cesarean section

(E) she received nalbuphine for relief of pruritus

233. You receive a phone call from an obstetrician who has just seen a patient with von Willebrand disease (vWD) for her first prenatal visit. He inquires as to the anesthetic-related implications of the patient’s disease during pregnancy and the use of neuraxial anesthesia in this patient. All of the following responses are true of vWD EXCEPT

(A) vWD is the most common inherited coagulopathy and affects 1-2% of the general population

(B) evidence-based recommendations for neuraxial anesthesia in the setting of vWD can be made

(D) the treatment of vWD depends on its severity and subtype

(E) vWD is not necessarily a contraindication to neuraxial anesthesia

DIRECTIONS: Use the following scenario to answer Questions 234–236: A 26-year-old G1P0 patient presents to the labor and delivery department at 35 weeks gestational age complaining of a headache and scotomata. Her blood pressure is 150/100, pulse is 84, and her oxygen saturation is 100% breathing room air. Physical examination reveals marked facial edema and a Mallampati 4 airway. Her cervix is 2 cm dilated. Laboratory values include a platelet count of 90,000/mm³, a 24-hour urine specimen containing more than 5 g of protein, and normal liver function tests. Physical examination reveals epigastric pain.

234. All of the following are consistent with a diagnosis of severe preeclampsia EXCEPT

(A) platelet count of 90,000/mm³

(B) headache

(D) diastolic blood pressure of 100 mm Hg

(E) epigastric pain

235. The obstetrician begins an infusion of magnesium sulfate and decides to induce labor in the patient given her diagnosis of severe preeclampsia. She then calls you to request an epidural. You inform the obstetrician that

(A) severe preeclampsia is a contraindication to epidural placement

(B) the platelet count is an absolute contraindication to the placement of an epidural

(D) you will obtain informed consent and place an epidural

(E) the patient should receive a spinal to reduce the risk of hematoma

236. The most common cause of mortality in a patient like this one is

(A) cardiac arrest

(B) renal failure

(D) respiratory arrest after inability to intubate

(E) cerebrovascular accident

237. A 26-year-old G2P0 patient requests an epidural. The epidural placement is uneventful. Twenty minutes later you are called to the labor room because the patient is complaining of shortness of breath and is still in pain. A quick sensory exam reveals a much higher level on the right side of the patient with a patchy sensory block. There is no fetal distress and the patient is oxygenating well. Your next step in the management of this patient should be to

(A) pull the catheter back 1 cm and administer another bolus of local anesthetic solution

(B) stop the epidural infusion, observe the patient, and administer another bolus of local anesthetic solution when the sensory level recedes

(C) stop the epidural infusion, observe the patient, replace the epidural catheter, and administer another bolus of local anesthetic solution once the level has receded.

(D) intubate the patient and provide supportive measures

(E) administer a bolus of fentanyl through the epidural catheter to enhance the block

238. You are called by an obstetrician to see an HIV-positive patient on her first postpartum day. She underwent an uneventful vaginal delivery under epidural anesthesia. She is now complaining of a positional headache and neck stiffness. You have a discussion about an epidural blood patch (EBP). You tell her

(A) given her HIV status an EBP is contraindicated and you recommend conservative treatment

(B) an EBP has a success rate of approximately 70% after the first attempt

(D) severe complications of EBP are rare and may include transient bradycardia, facial palsy, and arachnoiditis.

(E) the absence of a documented wet tap makes the diagnosis of postdural puncture headache (PDPH) unlikely in this patient

239. Regarding placental physiology, which one of the following drugs crosses the placenta in appreciable amounts?

(A) Atropine

(B) Glycopyrrolate

(D) Vecuronium

(E) Heparin

DIRECTIONS: Use the following scenario to answer Questions 240-241: An 18-year-old G2P1 patient presents for repeat cesarean section. She is 59 inches tall and underwent a previously uneventful primary cesarean section. Shortly after the administration of spinal anesthesia, the patient begins to complain of shortness of breath. Her blood pressure is 80/40 and her heart rate is 48 bpm. The patient tells you she is nauseated, short of breath, and her hands are tingling.

240. Initial management of this patient should include all of the following EXCEPT

(A) administration of ephedrine

(B) asking the patient to squeeze your hands with hers

(D) supplemental administration of oxygen

(E) placing the patient in the Trendelenburg position

241. Within a few minutes the patient becomes unresponsive, profoundly hypotensive, and apneic. Appropriate management would include all of the following EXCEPT

(A) positive pressure ventilation via endotracheal intubation

(B) left uterine displacement

(D) administration of 100% oxygen

(E) prompt administration of epinephrine to support maternal circulation

242. A 32-year-old G1P0 patient presents to the labor and delivery department in early labor. Her prenatal course is unremarkable except for a history of multiple sclerosis (MS). True statements regarding her care include all of the following EXCEPT

(A) an increase in body temperature of as little as 0.5°C can result in an exacerbation or relapse

(B) exaggerated responses to inhaled anesthetics can occur due to autonomic dysfunction

(D) epidural anesthesia is associated with greater risk of relapse than spinal anesthesia

(E) a hyperkalemic response to succinylcholine can be seen in patients with significant muscle atrophy

243. A 30-year-old G2P1 female presents for a repeat cesarean section at 40 weeks gestational age. Her prenatal course is complicated by recurrent pregnancy loss and she is positive for the lupus anticoagulant. She has been on unfractionated heparin 10,000 units subcutaneously twice a day throughout her third trimester. Her last dose was last evening (twelve hours ago). True statements regarding her care include

(A) regional anesthesia is safe and no further testing is necessary

(B) regional anesthesia is contraindicated in this patient

(D) a partial thromboplastin time and platelet count should be obtained prior to performing a regional anesthetic

(E) the peak effect of subcutaneous heparin is 4 h after subcutaneous injection

DIRECTIONS: Use the following scenario to answer Questions 244-245: A 27-year-old G2P1 female presents with a history of profound depression at 34 weeks gestational age. She had a recent suicide attempt and her psychiatrist now recommends electroconvulsive therapy (ECT). You are asked to counsel the patient regarding the use of ECT in pregnancy.

244. Which one of the following statements is true about ECT during pregnancy?

(A) The American Psychiatric Association recommends that ECT be deferred until the third trimester of pregnancy.

(B) Most of the psychotropic medicines have a long history of safe use in pregnancy.

(D) Your recommendation to the patient can be based on prospective, randomized controlled trials.

(E) The anesthetic agents used for ECT have a long history of safe use in pregnancy.

245. Appropriate measures for parturients undergoing ECT would include all of the following EXCEPT

(A) preoperative obstetric consultation

(B) monitoring of the fetal heart rate before and after ECT

(D) monitoring of uterine contractions after ECT

(E) left uterine displacement after 14 weeks gestational age

246. All of the following drugs may cause worsening of myasthenic symptoms EXCEPT

(A) oxytocin

(B) aminoglycoside antibiotics

(D) terbutaline

(E) carboprost tromethamine

247. A 27-year-old G2P1 female presents to you for consultation regarding a vaginal birth after cesarean section (VBAC). Her first cesarean was a low transverse incision for breech presentation. You tell her that

(A) VBAC is successful in less than half of patients in whom a low-transverse cesarean section was made during previous cesarean delivery

(B) epidural analgesia does not delay the diagnosis of uterine rupture

(D) the risk of uterine rupture is approximately 2%

(E) according to the American College of Obstetricians and Gynecologists (ACOG), anesthesia providers must be available within 30 min to provide emergency care for patients attempting VBAC

248. Which one of the following is the most common cause of severe postpartum hemorrhage?

(A) Lacerations

(B) Retained placental tissue

(D) Uterine atony

(E) Uterine inversion

249. A 38-year-old G0 patient opts for in vitro fertilization (IVF). She has undergone hormonal stimulation and is about to receive human chorionic gonadotropin (hCG) to induce oocyte maturation. She will present for transvaginal egg retrieval 36 h after administration of human chorionic gonadotropin (hCG). Which one of these anesthetic considerations is true?

(A) She will not need to fast if she is given conscious sedation.

(B) Paracervical block may be used as the sole anesthetic.

(D) Adding 10 mcg of fentanyl to intrathecal lidocaine solution improves postoperative analgesia but increases time to ambulation and discharge.

(E) General anesthesia decreases the successful fertilization rate of the retrieved oocytes.

DIRECTIONS: Use the following scenario to answer Questions 250-251: A 38-year-old G1P0 female at 39 weeks gestational age is being induced for preeclampsia. She is given a 4-g bolus of magnesium sulfate followed by an intravenous infusion at 2 g/h.

250. Which one of the following statements regarding the use of magnesium sulfate in this patient is true?

(A) Magnesium sulfate is eliminated primarily through the liver.

(B) Patellar reflexes are lost at serum magnesium levels of approximately 2 mg/dL.

(D) Therapeutic blood concentrations are 4-8 mg/dL.

(E) Magnesium sulfate does not cross the placenta.

251. The patient undergoes an uneventful delivery and is sent to the postpartum floor on an infusion of magnesium sulfate for twenty-four hours. A nurse discovers the patient is having breathing difficulty and you are paged stat to the room. Upon arrival, you note that the patient is lethargic. Her blood pressure is 110/60, heart rate is 70, and she is in severe respiratory distress. Management of this patient would include all of the following EXCEPT

(A) administration of epinephrine 1 mg intravenously

(B) support of respiration with bag-mask and possible endotracheal intubation

(D) administration of calcium gluconate 1 g intravenously

(E) obtaining a serum magnesium level

252. A 30-year-old G1P0 patient presents for antenatal counseling regarding her history of a malignant hyperthermia (MH) episode. Which one of the following recommendations is true?

(A) MH is inherited in an autosomal recessive fashion.

(B) There is a 25% chance that the fetus will be MH-susceptible.

(D) Her child will need to be treated with non-triggering anesthetics in the future unless the child undergoes caffeine-halothane contracture testing and the testing is negative.

(E) Once labor begins, she will be given prophylactic dantrolene that does not cross the placenta.

253. An infant with a heart rate of 70, a weak cry, minimal muscle flexion, a grimace to oropharyngeal suctioning and acrocyanosis at five minutes would receive an Apgar score of

(A) 2

(B) 4

(D) 6

(E) 7

DIRECTIONS: Use the following scenario to answer Questions 254-255: You are called to the trauma room where you encounter a 31-year-old G2P1 patient at 34 weeks estimated gestational age. She was involved in a motor vehicle accident and has suffered multiple injuries. She is actively being resuscitated. Fetal heart tones are present. Shortly after your arrival, the patient goes into cardiac arrest during the resuscitation. The obstetrical team is present in the trauma room.

254. All of the following statements regarding the resuscitation of this patient are true EXCEPT

(A) left uterine displacement should be maintained during the resuscitation

(B) chest compressions should be performed slightly above the center of the sternum

(D) vasopressor agents may decrease blood flow to the uterus

(E) standard ACLS drug dosages should be adjusted upward for pregnant patients

255. It has been four minutes since resuscitative measures were instituted. The patient remains asystolic. You should now consider

(A) administering a biphasic shock of 200 J

(B) administering a monophasic shock of 360 J

(D) administering a second dose of vasopressin

(E) calling the code

256. Well known gastrointestinal changes that occur during pregnancy include all of the following EXCEPT

(A) the combination of esophageal displacement into the thorax and progestin result in a lowering of the lower esophageal sphincter tone

(B) gastric emptying of liquid and solid materials is not altered during pregnancy

(D) gastric emptying is slowed during labor

(E) epidural anesthesia using local anesthetics only delays gastric emptying

257. The most reliable means of detecting uterine rupture in this patient is

(A) maternal tachycardia

(B) uterine tenderness

(D) a non-reassuring fetal heart rate pattern

(E) maternal complaint of pain during labor

258. Regarding placental transfer of drugs, which one of the following favors increased maternal to fetal drug transfer?

(A) Molecular weight less than 1,000 Daltons

(B) Hydrophilic substance

(D) High bound drug fraction

(E) Lower portion of unionized drug in maternal plasma

259. In order for an epidural to relieve the second stage of labor, the epidural must cover which one of these dermatomes?

(A) T10-L1

(B) T11-T12

(D) L3-L5

(E) S2-S4

260. Well known endocrine changes that occur during pregnancy include all of the following EXCEPT

(A) the thyroid gland enlarges during pregnancy

(B) estrogen induces an increase in thyroid-binding globulin which results in a relative hyperthyroid state during pregnancy

(D) pregnant patients are insulin resistant primarily due to placental production of lactogen

(E) cortisol levels are increased during pregnancy

DIRECTIONS: Use the following figure to answer Question 261:

261. You are finishing a routine preoperative evaluation on a patient for an elective repeat cesarean section in the antepartum assessment area when you view the following fetal heart tracing on a patient in the next room who is being assessed for decreased fetal movement at 36 weeks. She is contracting spontaneously. This is an example of

(A) early decelerations

(B) a reactive non-stress test

(D) fetal bradycardia

(E) a positive oxytocin contraction test (OCT)

262. A variety of physiologic changes in uteroplacental blood flow occur during pregnancy and include which one of the following characteristics?

(A) The uterus accounts for roughly 12% of the cardiac output at term.

(B) Uteroplacental blood flow is widely autoregulated during pregnancy.

(D) The main supply of blood to the uterus is from the uterine arteries that arise from the aorta.

(E) General anesthetic doses typically used decrease uterine blood flow.

263. A 27-year-old G2P1 female presents for anesthetic consultation at 16 weeks gestational age. Her prenatal course is significant for a history of mild mitral stenosis (MS). She is currently asymptomatic (NYHA Class 1 disease). You tell her that all of the following statements about her condition are true EXCEPT

(A) approximately 25% of patients with mitral stenosis first experience symptoms during pregnancy

(B) mitral stenosis is the most commonly encountered valvular lesion in pregnancy

(D) ephedrine is the pressor of choice to treat hypotension

(E) maternal expulsive efforts during the second stage of labor are discouraged

264. Which one of the following statements concerning the management of a parturient with an unanticipated difficult airway is consistent with the ASA difficult airway algorithm?

(A) In an elective cesarean section, proceed under mask ventilation if the patient has had nothing by mouth.

(B) Never attempt blind nasal intubation because of the risk of bleeding from engorged airways.

(C) If able to ventilate with mask and the fetus is in serious distress, no additional steps should be taken to obtain a secure airway and delivery should proceed immediately.

(D) Never attempt cricothyrotomy in a preeclamptic patient because of potential coagulopathy.

(E) If unable to ventilate or intubate, attempt to place an LMA with cricoid pressure and if successful consider proceeding to cesarean section in the presence of fetal distress.

265. Which one of the following changes in lab values is expected during pregnancy?

(A) Decreased hematocrit

(B) Increased PCO₂

(D) Increased creatinine

(E) Decreased factors VII, VIII, X, and fibrinogen

266. Nonobstetric surgery during pregnancy occurs with an estimated frequency of 0.3% to 2.2%. Anesthetic concerns regarding nonobstetric surgery during pregnancy include all of the following EXCEPT

(A) rapid sequence induction should be performed after 16 weeks gestational age when general anesthesia is required

(B) regional anesthesia, when appropriate, is a reasonable alternative

(C) aspiration prophylaxis should be accomplished with either a nonparticulate antacid and/or a histamine H₂ antagonist combined with a gastric prokinetic agent

(D) benzodiazepines are contraindicated due to the increased incidence of cleft palate

(E) left uterine displacement for the prevention of aortocaval compression is not necessary in the first trimester

DIRECTIONS: Use the following photograph to answer Questions 267-268:

A 27-year-old patient presents at ten weeks gestation with abnormal uterine bleeding, hyperemesis, and bilaterally enlarged ovarian cysts. On exam her uterus is greater than expected size and her beta-hCG is markedly elevated (100,000 mIU/mL). An ultrasound is obtained and is shown above.

267. The most likely diagnosis in this patient is

(A) ectopic pregnancy

(B) incomplete spontaneous abortion

(D) molar pregnancy

(E) septic abortion

268. Proper anesthetic management of this patient would include all of the following EXCEPT

(A) blood products should be immediately available

(B) two large bore intravenous catheters should be placed

(D) close observation of the patient post procedure for evidence of hemorrhage or cardiopulmonary distress

(E) general anesthesia is preferred

269. A parturient is diagnosed with retained placenta after delivery and requires manual exploration of the uterus. All of the following are acceptable management strategies EXCEPT

(A) intravenous analgesia

(B) epidural analgesia

(D) intravenous nitroglycerine, 400 mcg

(E) induction of general anesthesia with 1 mg/kg ketamine

DIRECTIONS: Use the following figure to answer Questions 270-271:

270. The tracing in the graph shows a pattern referred to as

(A) late deceleration

(B) variable deceleration

(D) maximal deceleration

(E) late acceleration

271. The type of heart rate tracing shown in the graph is usually associated with

(A) cord compression

(B) placental insufficiency

(D) acute fetal asphyxia

(E) tetanic contraction

272. You are asked to place an epidural in a patient who is laboring with a singleton in breech presentation. All of the following are true regarding breech presentation EXCEPT

(A) a higher incidence of congenital abnormality

(B) a lower frequency of prolapsed umbilical cord

(D) causes of breech presentation include preterm delivery, multiple gestation, and uterine abnormalities

(E) it accounts for approximately 3-4% of all pregnancies

273. The usual blood loss associated with an uncomplicated vaginal delivery of twins is approximately

(A) 400 mL

(B) 600 mL

(D) 1000 mL

(E) 1200 mL

274. A 27-year-old G1P0 patient is being treated for preterm labor with terbutaline. An adverse effect of terbutaline used for preterm labor is

(A) cardiac arrhythmia

(B) hyperkalemia

(D) hypertension

(E) hypoglycemia

275. Nerve injury during labor and delivery can result from all of the following EXCEPT

(A) compression of lumbosacral trunk by the head of fetus

(B) peroneal nerve injury by lithotomy stirrup

(D) femoral nerve compression by the lithotomy stirrup

(E) chemical contamination of the subarachnoid space

276. A 35-year-old heroin-addicted parturient in labor is requesting pain relief. Which one of the following options is LEAST desirable?

(A) Meperidine

(B) Continuous epidural analgesia

(D) Butorphanol

(E) Lumbar sympathetic block

277. Uterine rupture is an obstetrical emergency often necessitating general anesthesia. It is associated with significant maternal morbidity and increases neonatal mortality by 60-fold. Conditions associated with uterine rupture include all of the following EXCEPT

(A) previous uterine surgery

(B) trauma

(D) intrauterine manipulation

(E) twin gestation

278. Well-known changes that occur in the central nervous system of the parturient include all of the following conditions EXCEPT

(A) nerve fibers have increased sensitivity to local anesthetics

(B) MAC for inhalational agents is decreased by approximately 40%

(D) no change in dose requirement for local anesthetic in the first trimester

(E) spinal CSF volume is reduced

DIRECTIONS: Use the following scenario to answer Questions 279-280: You are called emergently to a delivery room where a patient has just undergone a natural childbirth. The nurse informs you that the patient is bleeding and asks for your assistance. The obstetrician states there is a uterine inversion. The patient is pale with a blood pressure of 60/40. Her pulse is 125. She is actively bleeding. She has a single 18-gauge IV that is infusing lactated Ringer solution containing 20 U/L of oxytocin. The IV is running wide-open.

279. Initial steps in the management of this patient include all of the following EXCEPT

(A) obtain large-bore IV access

(B) place the patient in the Trendelenburg position and administer vasopressors as needed

(D) continue infusing the IV solution containing oxytocin

(E) immediate attempt at replacement of the uterus

280. The obstetrician’s initial attempts to replace the uterus are unsuccessful. He asks for your assistance. While preparing to move to the operating room, which one of the following maneuvers may be of most benefit?

(A) IV bolus of 2 g of magnesium sulfate

(B) IM injection of 5 mg of ritodrine

(D) IV bolus of 50–100 mcg of nitroglycerine

(E) placement of a saddle block

281. Prophylactic measures taken to prevent maternal hypotension during and following spinal anesthesia include all of the following EXCEPT

(A) administration of 500-1000 mL of crystalloid solution

(B) left lateral displacement of the uterus

(D) placement of the spinal anesthetic with the patient in the lateral position

(E) infusion of a vasopressor

282. An obstetrician asks you to stand by in case he needs to perform an urgent cesarean section. His patient is 8 cm dilated. The fetal heart rate pattern is nonreassuring and there is no fetal response to fetal scalp stimulation. The patient is comfortable with a working epidural in place. He states he is going to perform fetal blood capillary pH testing. All of the following statements are true regarding fetal blood capillary pH testing EXCEPT

(A) it is a method that cannot be used to assess fetal well-being during labor of a breech presentation

(B) a fetal scalp pH of 7.25 or higher is considered normal

(D) a fetal scalp pH of 7.20-7.24 is intermediate and requires close monitoring and repeat sampling

(E) it requires adequate dilation of the cervix

283. The one finding present in eclamptic patients and not in preeclamptics is

(A) hyperreflexia

(B) decreased uteroplacental perfusion

(D) treatment with magnesium sulfate

(E) general vasoconstriction

284. A change in the anatomy or physiology of the stomach that is associated with pregnancy is

(A) decreased acid secretion

(B) decreased gastric emptying time

(D) incompetence of the lower esophageal sphincter beginning in the first trimester

(E) epidural analgesia using only local anesthetics slows gastric emptying

285. You are called to the postpartum floor to perform an epidural blood patch (EBP) on a patient who had a wet tap two days prior during the placement of her labor epidural. You explain to her that all of the following are true of an epidural blood patch EXCEPT

(A) the success rate for a first EBP approaches 85%

(B) prophylactic epidural saline bolus is effective in decreasing the incidence of postdural puncture headache (PDPH)

(D) 15–20 mL of aseptically obtained autologous blood is typically used for the EBP

(E) 95% of postdural puncture headaches last less than one week

286. You are called to the delivery room and are asked to assist in the resuscitation of a newborn term infant. The infant is not breathing and the heart rate is less than 100. Steps to take include all of the following EXCEPT

(A) provide warmth, clear the airway and dry, stimulate, and reposition the infant

(B) if the infant remains apneic or the heart rate is less than 100, provide positive pressure ventilation

(D) during the first assisted, breath positive pressure at 20 cm H₂O should be maintained for 4-5 sec at the end of inspiration to overcome the surface tension of the lungs and open up the alveoli

(E) if mask ventilation lasts more than 2-3 min, the stomach should be emptied with an orogastric tube

287. A 27-year-old paraplegic patient with a T6 lesion presents to the labor and delivery suite in early labor. She is 4 cm dilated and requests an epidural. Which one of the following statements regarding her anesthetic management is true?

(A) Spinal anesthesia is contraindicated in this patient.

(B) Neuraxial anesthesia is unnecessary in this patient since the patient has no sensation below the T6 level.

(D) Patients with a spinal cord injury are more prone to orthostatic hypotension that can contribute to a decrease in uteroplacental perfusion.

(E) If general anesthesia is necessary, a depolarizing agent may be used without reservation.

288. The local anesthetic that attains the lowest fetal concentration relative to maternal concentration is

(A) lidocaine

(B) ropivacaine

(D) mepivacaine

(E) bupivacaine

DIRECTIONS: Use the following scenario to answer Questions 289-290. You are asked to evaluate a 30-year-old G4P3 female who presents at 37 weeks gestation for her third cesarean section as well as tubal ligation. Her prenatal course is complicated by known placenta previa. She has had no antepartum bleeding. She currently weighs 250 pounds and is 62 inches tall. Her airway exam reveals a Mallampati class 4 with normal range of motion.

289. During the anesthesia interview you advise the patient that

(A) her risk of placenta accreta is 25%

(B) her risk of placenta accreta is 11%

(D) spinal anesthesia is contraindicated

(E) she must undergo general anesthesia for her repeat cesarean section

290. During your preoperative interview, you advise her of all of the following EXCEPT

(A) two large-bore intravenous catheters will be placed

(B) she will be typed and crossmatched for blood

(D) an obstetrical hysterectomy may be required

(E) the procedure will be performed under spinal anesthesia to avoid a potentially difficult airway

291. A neuropathy manifested as numbness, tingling, burning, or other paresthesia that is probably the most commonly encountered neuropathy related to childbirth is

(A) compression of the lumbosacral trunk

(B) obturator nerve palsy

(D) sciatic nervy palsy

(E) lateral femoral cutaneous nerve palsy

292. You are called by a colleague who has tried multiple times to place an epidural in a laboring patient who had corrective surgery for scoliosis. She asks about the placement of a caudal anesthetic. You reply that all of the following statements are true about her condition EXCEPT

(A) caudal anesthesia is an acceptable alternative in this patient

(B) identification of the sacral hiatus is necessary

(C) a test dose similar to that used during lumbar epidural placement is not necessary prior to administration of local anesthetic

(D) accurate placement of the caudal needle is confirmed by the “feel” of the needle passing through the sacrococcygeal ligament that overlies the sacral hiatus between the sacral cornua

(E) the needle should only be advanced 1 to 2 cm into the caudal canal

293. Patient-controlled analgesia (PCA) is a viable alternative for pain management during labor in patients with a contraindication to or unsuccessful attempt at neuraxial analgesia. Remifentanil PCA has more recently been used. True statements regarding remifentanil PCA include all of the following EXCEPT

(A) plasma concentrations of remifentanil in pregnant patients are about half those found in nonpregnant patients

(B) remifentanil rapidly crossed the placenta

(D) the context-sensitive half-time of 3.5 min is not affected by the duration of infusion

(E) remifentanil is rapidly metabolized by plasma and tissue esterases to an inactive metabolite

294. In a pregnant woman at term, you would expect an increase in all of the following values EXCEPT

(A) functional residual capacity

(B) dead space

(D) lung compliance

(E) inspiratory reserve volume

295. A 30-year-old G3P2 female presents for an anesthesia consultation. Her prenatal course is significant for a history of HSV-2 infection. All of the following statements regarding her care are true EXCEPT

(A) primary herpes infection is associated with viremia

(B) asymptomatic shedding of the virus may occur in the genital tract

(D) neuraxial anesthesia is contraindicated in a patient with active recurrent HSV-2 infection in labor

(E) epidural or intrathecal administration of morphine increases the risk of recurrence of HSV-1, but not HSV-2, infection in obstetrical patients

296. A 30-year-old G1P0 female at 18 weeks estimated gestational age has just been diagnosed with a pheochromocytoma and presents for an anesthetic consultation. You tell her that all of the following statements are true EXCEPT

(A) early laparoscopic resection of the tumor is possible prior to the third trimester

(B) pheochromocytoma is associated with an increased incidence of both fetal death and intrauterine growth restriction (IUGR)

(C) if surgical resection is not accomplished prior to delivery, spontaneous vaginal delivery is the preferred method of delivery

(D) phenoxybenzamine is the most commonly prescribed α-adrenoceptor antagonist used

(E) nicardipine may be used intraoperatively to prevent hypertension during resection of the tumor

297. True statements regarding fetal electronic monitoring during nonobstetric surgery include all of the following EXCEPT

(A) the American College of Obstetricians and Gynecologists (ACOG) acknowledge there are no data to allow specific recommendations for fetal heart rate (FHR) monitoring for obstetric patients undergoing nonobstetric surgery

(B) monitoring should be performed before and after surgery

(D) a decrease in FHR variability during general anesthesia is an indication of fetal compromise and an indication for cesarean delivery

(E) an experienced obstetric provider should be present to monitor and interpret the FHR tracing and uterine activity

298. Plasma cholinesterase concentrations during pregnancy are

(A) highest at term

(B) unchanged from normal levels

(D) decreased resulting in a clinically significant prolongation of amide type local anesthetics

(E) decreased to a degree not resulting in a clinically significant prolongation of succinylcholine

299. You are confronted with a 28-year-old G1P0 female with achondroplasia. She presents for an elective cesarean section at 39 weeks gestational age. True statements regarding her achondroplasia and obstetrical anesthetic management include all of the following EXCEPT

(A) marked lumbar lordosis and scoliosis may cause technical difficulties during attempts at neuraxial anesthesia

(B) it may be difficult to estimate the appropriate dose of local anesthetic for single-shot spinal anesthesia

(D) achondroplasia is inherited as an autosomal dominant mode, although most cases occur as a result of spontaneous mutation

(E) although a higher incidence of difficult intubation has been reported in achondroplastic patients, most reports note no difficulty in airway management.

300. A 27-year-old G1P0 woman is admitted at term for an ex utero intrapartum therapy (EXIT) procedure. The surgeons plan to excise a large embryonic cervical tumor. All of the following are characteristics of the maternal and fetal anesthetic care EXCEPT

(A) placement of an epidural catheter for postoperative maternal pain control

(B) pulmonary denitrogenation, rapid sequence induction, and endotracheal intubation of the mother

(C) fetal anesthesia provided by intramuscular injection of opioid and a paralytic agent either by ultrasound guidance prior to uterine incision or directly after hysterotomy and delivery of the fetus

(D) 1 to 1.5 MAC of volatile inhalational agent is required for the procedure

(E) fetal tracheal intubation after hysterotomy with maintenance of fetoplacental circulation until the procedure is completed.

DIRECTIONS: Use the following figure to answer Question 301:

301. The figure above shows the change in cardiac output with pregnancy. The discrepancy in the two lines is due primarily to the effect

(A) on respiration

(B) on uterine blood flow

(D) of pressure on the aorta

(E) on the central nervous system

302. Adjuvants such as epinephrine or bicarbonate are often used during obstetrical epidural anesthesia. True statements regarding the use of these adjuvants include all of the following EXCEPT

(A) epinephrine is more effective at prolonging the action of short-acting local anesthetics than longer-acting agents

(B) the addition of sodium bicarbonate hastens the onset of the block by increasing the pH closer to the pKa of the local anesthetic

(D) epinephrine has intrinsic analgesic effects via stimulation of pre-synaptic α₂-adrenoceptors that contribute to greater reliability and intensity of the block

(E) alkalization of bupivacaine must be performed carefully because the margin between satisfactory alkalization and precipitation is narrow

303. Which one of the following is the correct statement regarding drug action and placental transfer in a parturient?

(A) Placental transfer is minimal with muscle relaxants.

(B) Opioids do not cross the placenta.

(D) Nitrous oxide is contraindicated for cesarean section secondary to interference with vitamin B₁₂ synthesis.

(E) Thiopental does not cross the placenta.

304. True statements regarding total spinal anesthesia include all of the following EXCEPT

(A) it is a rare complication that can result from both intrathecal or epidural administration of local anesthetic

(B) it cannot result from subdural administration of local anesthetic

(C) supportive measures to provide oxygenation and prevent aspiration, including endotracheal intubation, may be necessary

(D) preventative measures may include waiting for a partial spinal to wear off and then administering a second spinal in the case of elective cesarean section

(E) conversion to general anesthesia may be necessary

305. Well-known cardiovascular changes that occur at term in pregnancy include which one of the following parameters?

(A) A 25% decrease in heart rate

(B) A 20% increase in systemic vascular resistance

(D) A decrease in left ventricular end-diastolic volume

(E) A decrease in left ventricular end-systolic volume

DIRECTIONS (Questions 306-307): Each group of items below consists of lettered headings followed by a list of numbered phrases or statements. For each numbered phrase or statement, select the ONE lettered heading or component that is most closely associated with it. Each lettered heading or component may be selected once, more than once, or not at all.

(A) Placenta previa

(B) Placenta accreta

(D) Ruptured uterus

(E) Placental abruption

(F) Amniotic fluid embolus

(G) Severe preeclampsia

For each patient, select the most likely etiology.

306. A 27-year-old primipara at term in labor at 8 cm ruptures her membranes spontaneously, sits up, and states, “My heart.” She then becomes hypotensive and unresponsive. She begins to have significant vaginal bleeding shortly afterwards.

307. A 30-year-old parturient at 32 weeks gestational age presents to the labor and delivery suite complaining of decreased fetal movement and abdominal pain. She admits to chronic cocaine use throughout her pregnancy. Her blood pressure is 120/60. Her abdomen is firm. A non-stress test is non-reassuring. An ultrasound is performed which reveals no abnormal placental findings.

DIRECTIONS (Questions 308-309): Each group of items below consists of lettered headings followed by a list of numbered phrases or statements. For each numbered phrase or statement, select the ONE lettered heading or component that is most closely associated with it. Each lettered heading or component may be selected once, more than once, or not at all.

(A) Oxytocin

(B) Mifepristone

(D) Vasopressin

(E) Methysergide

(F) Misoprostol

(G) Methylergonovine

(H) Methylprednisolone

For each patient, select the most appropriate medication.

308. You are called to a room where a 27-year-old G6P6 female has just delivered via natural childbirth and is bleeding. The patient has a history of severe reactive airway disease and upon entering the room she is actively wheezing. The obstetrician states the uterus remains boggy and the patient continues to bleed despite the administration of oxytocin and methylergonovine.

309. In a patient with excessive postpartum bleeding, this medication is intended to be administered solely as an intramuscular or intramyometrial injection because it may cause severe hypertension when injected as an IV bolus.

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