1.
(a) F(b) T(c) F(d) T(e) T
Explanations:
Venous thromboembolism is the main cause of direct maternal mortality in developed countries but is less prominent in audits of severe morbidity, probably because it is often diagnosed postpartum after discharge from the maternity unit. PPH and severe pre-eclampsia/eclampsia are consistently the most common causes of severe maternal morbidity, however it is defined, in both developed and developing countries. Amniotic fluid embolism is an important cause of maternal death, but because of its high death to case ratio it is more often fatal than a cause of morbidity. Uterine rupture and its sequelae is an important cause of morbidity but much less common than haemorrhage and severe preclampsia/eclampsia. With rising caesarean section rates the incidence of uterine rupture is not falling.
2.(a) F(b) F(c) T(d) F(e) T
Explanations:
Liver failure is a cause of vasodilatory high output cardiac shock, however in pregnancy more common causes include those relating to spinal anaesthesia and septic shock. In pregnancy it is relatively easy to induce pulmonary oedema by giving excessive fluid. Oliguria is usually well tolerated, especially in pre-eclampsia, and the inclination to give fluid ‘blindly’ in oliguric states should be much less than outside the setting of pregnancy. When given, monitoring should be in place and the response to cautious fluid challenges observed. Maternal CO increases early in pregnancy to cope with the increased oxygen demand by the fetus, as early as 8 weeks gestation, and this continues 2–12 weeks into the puerperium. Amiodarone is not recommended in pregnancy. Myocarditis and peripartum cardiomyopathy can both lead to catastrophic low CO and early specialist input is important, as a significant number require mechanical supportive therapy.
3.(a) T(b) F(c) T(d) T(e) T
Explanations:
The differential diagnosis of respiratory failure in pregnancy is broad. Respiratory failure due to asthma does occur, although mild asthma exacerbations are more common. It is imperative to ensure good compliance with all asthma medications. CPAP is a very effective treatment for cardiogenic pulmonary oedema, as giving positive airway pressure improves alveolar oedema and therefore lung compliance and improved oxygenation. Vasodilator treatment, for example with nitrates or hydralazine, is also very good for acute heart failure. Pregnant women may indeed be harder to ventilate, both invasively and non-invasively. This is because they need higher airway pressures with an increased abdominal girth and chest wall thickness (so poor chest wall compliance) and they have higher ventilatory requirements to cope with the 20% increase in maternal oxygen demand. They are also more prone to oxygen desaturation and are at increased risk of gastric acid aspiration. ARDS has many causes, and these may be direct pulmonary causes such as pneumonia, or indirect extra-pulmonary causes such as sepsis from any other site. As in outside pregnancy, the development of VAP should be minimized by simple manouevres such as reducing gastric acid aspiration, maintaining good mouth care and avoiding unnecessary re-intubations.
4.(a) F(b) F(c) T(d) T(e) T
Explanations:
Cardiac arrest is rare, occurring in about 1 in 30,000 late pregnancies, and, unlike outside pregnancy is rarely related to a primary cardiac disorder. Inadequate ventilation leads to rapid oxygen desaturations due to a reduced functional residual capacity (FRC) and increased oxygen demand. FRC reduces by 20% and oxygen consumption increases by 15–20%. The fetus needs to be delivered to remove the pressure of the gravid uterus on the vena cava disrupting the transit of resuscitation drugs. Removal of the fetus results in an increase in cardiac output by 60–80%. Delivery of drugs to the heart will consequently be much more effective. Aorto-caval compression significantly affects cardiac output by reducing venous return to the heart. This can be avoided by adopting the left lateral position up to 30 degrees using a cushion wedge or the rescuers knee form a ‘human wedge’. Peri-mortem delivery is associated with improved fetal outcomes compared to post mortem delivery of the fetus and is best considered early and implemented if there has not been a response after 5min.
5.(a) T(b) T(c) F(d) T(e) F
Explanations:
Systemic vascular resistance does fall in the 1st trimester of pregnancy but the mechanisms which mediate this are not conclusive. The fall may be mediated by increasing levels of progesterone and vasodilators, such as nitric oxide, which cause peripheral arterial vasodilatation. This creates an ‘underfill’ signal which triggers an increase in cardiac output and sodium/water retention to maintain blood pressure.
Cardiac output increases by 30–50% and peaks at the end of the 2nd trimester. Oxygen consumption actually increases by 30–50mlmin, the majority of which is used for increased maternal metabolic demands – mainly the kidneys – with the excess supplying the developing fetus. This increase is associated with a 40% increase in ventilation; achieved by an increase in tidal volume rather than respiratory rate. The renal system undergoes significant structural and functional changes during pregnancy to compensate for the cardiovascular alterations that occur. GFR increases by 40–50% by the end of the 1st trimester and is maintained at this level until 36 weeks. TSH falls in the 1st trimester then rises slowly towards term. Thyroid function tests are affected by oestrogen mediated thyroid binding globulin, the similarity of the β sub-unit of HcG to TSH and a decrease in the availability of iodide.
6.(a) F(b) T(c) T(d) F(e) F
Explanations:
Invasive blood pressure measurements are more direct and tend to give lower measurements than standard non-invasive techniques. This is of importance in the high dependency setting. All methods used in pregnancy should be validated to the standards recommended by the British Hypertension Society and the Association for the Advancement of Medical Instrumentation. The accuracy of oxygen saturation monitoring can be affected by severe anaemia and also poor peripheral signals, caused by, for example, shock, nail varnish and venous congestion. In recent years the safety profile of PACs has been called into question due to the hazards of insertion or incorrect interpretation of the measurements obtained. It is now recommended that their use be restricted to critically ill patients only. Doppler echocardiography has been well validated for use in normal and complex hypertensive pregnancies: and in appropriately skilled hands, complete haemodynamic assessments are now possible. In contrast to other invasive and non-invasive methods, echocardiography can also give direct visual information about cardiac function. In non-pregnant patients CVP is very similar to PCWP but the association is more variable in pregnancy and particularly pre-eclampsia where individuals are very fluid sensitive. Studies have shown dangerously high wedge pressures in people with apparently normal CVPs of around 8mmHg, therefore fluid management on the basis of CVP alone is not recommended in pregnancies complicated by proteinuric hypertension.
7.(a) T(b) F(c) T(d) T(e) T
Explanations:
The Henderson-Hesselbach equation is the most widely used method of analysing and interpreting acid base problems, by defining carbon dioxide and bicarbonate in aqueous solutions. This method is useful for quantifying respiratory derangements but is limited where metabolic problems are involved. The respiratory centre can respond rapidly to changes in pH by regulating alveolar ventilation, whereas the renal system acts more slowly by controlling the homeostasis of bicarbonate and metabolic acids. Where the pH is abnormal, an important diagnostic step is to assess the level of pCO2 and see if it is consistent with the change in pH. An acidotic patient with a raised pCO2 or an alkalotic patient with a low pCO2, are both suggestive of primary respiratory causes. Where the pCO2 is normal or does not adequately explain the pH abnormality, an assessment of bicarbonate and base excess is required. Other causes of metabolic acidosis include diabetic ketoacidosis, lactic acidosis, vomiting and/or diarrhoea and renal tubular acidosis. When using traditional methods of acid based analysis, the anion gap, which represents unmeasured anions in plasma, is used to narrow down the possible causes of the metabolic acidosis. It is usually either normal or high.
8.(a) F(b) T(c) T(d) F(e) F
Explanations:
To estimate the fluid loss in DKA, work on 100ml/kg bodyweight. Give one litre of 0.9% normal saline over the first hour. Correct three quarters of the fluid deficit over the first 24h by giving 250–500ml/h of 0.45% saline over the next 12h. If the glucose is below 14mmol/l change to 5% dextrose/0.45% saline and continue fluids for 24–48h to correct the deficit. A short acting insulin and normal saline solution of 10ml=1Unit insulin needs to be made and the tubing must be flushed with the solution before the insulin infusion is started. Start with a bolus of 0.1U/kg intravenously immediately and then give 0.1U/kg/h insulin. Check serum glucose and arterial blood gas and ketones every 2h. Increase the insulin infusion if the serum glucose does not decrease by at least 5mmol/h. If the pH is between 6.9 and 7.0, 50mmol/l NaHCO3 should be added to 200ml 0.45% saline and given over 1h. If the pH is less than 6.9, 100mmol/l NaHCO3 should be added to 400ml 0.45% saline and given over 1h and repeat 2 hourly till the pH is more than 7.0. Potassium needs to be replaced. If the serum potassium is more than 5mmol/l repeat every 2h, if the potassium is between 3.0 and 5.0mmol/l add 20mmol potassium chloride in each litre of fluid to keep the potassium between 4 and 5mmol/l. If the potassium is less than 3mmol/l add 40mmol potassium chloride to the initial fluid and delay the insulin therapy until the potassium level is more than 3mmol/l.
9.(a) F(b) T(c) F(d) F(e) T
Explanations:
A lupus flare up is diagnosed with the following: a new or worsening photosensitivity or discoid or any other cutaneous rash that is the result of lupus, acute sinovitis, pericarditis, pleuritis, nasopharyngeal ulcers, fever in the absence of infection, thrombocytopenia usually less than a 100×109/l, leucopenia less than 4×109/l, haemolytic anemia, worsening of the proteinuria to more than 2gm/24h and a deterioration of more than 30%, recurrence of active urinary sediment, an increase of more than 0.25 in the Lupus Activity Index in Pregnancy scale (LAI-P), decrease in serum complement, rise in anti-DNA titre. Leucopenia and falling complement levels are not seen in PET.
10.(a) T(b) T(c) F(d) F(e) T
Explanations:
Patients on chronic treatment with oral steroids of more than 7.5mg/day for more than 14 days have suppression of their pituitary adrenal axis and require parental hydrocortisone 100mg three to four times/day until they can take oral treatment again or until the labour is finished. This combination of hypertension and the classical triad of paroxysmal headache, sweating and palpitations have a sensitivity of 91% and a specificity of 94% for diagnosing phaeochromocytoma. Plasmapheresis and intravenous immunoglobulin are the best treatment option for a myaesthenic crisis. Plasmapheresis is safe in pregnancy and is used for rapid control especially when the patient presents with a crisis. The improvement is only effective for 4–10 weeks. The features of SLTA include a silent chest where the airways are so narrow they cannot generate a wheeze and cyanosis reflecting major hypoxia.
11.(a) F(b) F(c) F(d) F(e) T
Explanations:
The clinical presentation of a patient with thyroid storm includes the following: Excessive sweating, Severe pyrexia, Cardiac failure, Tachycardia, Atrial fibrillation, Tachyarrythmias, Hypertension, Altered mental status which include a spectrum from agitation to coma, Vomiting, Diarrhoea, Hyperglycaemia, Acute abdominal pain and Hypovolaemia. Women with severe pre-eclampsia can have a tachycardia, hypertension, altered mental state and vomiting. Severe pyrexia is not a feature of severe pre-eclampsia.
12.(a) F(b) F(c) T(d) T(e) F
Explanations:
Outreach care has not been proven to be beneficial in the obstetric population. Nor have its track and trigger systems as the current data is based on non-pregnant populations. Despite marked physiological respiratory changes in pregnancy, derangements of function should be thoroughly investigated as for non-pregnant patients. Outreach care is an excellent example of multi-disciplinary team care and relies on cooperation between interested parties. Single parameter models have been shown to be as reliable as multiple parameter.
13.(a) F(b) T(c) F(d) F(e) T
Explanations:
Unstable patients should not be transferred out of their primary clinical care area where they have easily available resuscitation and operative equipment and staff. The patient should spend the minimum time away from the primary clinical care area, so it is prudent for all radiology suites to be set up for timely performance of procedures. Only staff suitably trained in the management of critically ill pregnant women should transfer patients. Appropriate equipment should always be available for transfer in the event of worsening clinical condition. Ongoing MDT management is vital for optimal outcome in obstetric patients.
14.(a) T(b) F(c) F(d) T(e) F
Explanations:
One major drawback of existing scoring systems is that they have been validated on the general non-pregnant population. They do not therefore accurately predict mortality, outcomes or take into account physiological changes in pregnancy that make the young and generally fit and healthy pregnant population different. Larger national data would help to improve current scoring systems as a greater volume of data would make sub-group analysis more reliable.
15.(a) F(b) F(c) T(d) F(e) T
Explanations:
Over 50% of women who died did so because they unfortunately received some level of suboptimal care within both the direct and indirect pathologies. CEMACH suggests that factors which contributed to substandard care included conditions which were ineffectively diagnosed, conditions which received ineffective or wrong treatment, failure of staff to recognize or act upon the severity of critical illness, care which was not consistent with agreed guidelines and poor communication between disciplines. It has also been identified within the CEMACH reports that midwifery staff fail to call upon the relevant senior medical professionals capable of managing critical situations, with junior doctors at times attending women and misdiagnosing conditions.
16.(a) T(b) F(c) T(d) F(e) T
Explanations:
A study exploring midwives recognition and management of critical illness has addressed some of the difficulties facing midwives managing the care of the critically ill obstetric woman. Findings suggested more experienced midwives seemed more able to apply pattern recognition when recognizing early signs of deterioration in sick patients. This appears to be more evident amongst midwives with previous nursing experience and less evident in midwives entering the profession via the direct entry route. Lack of support for midwives resulted in discrepancies being made during observation, monitoring and communication. Midwives made little reference to the clinical significance of certain vital signs and how to correctly apply these to practice. Regarding staffing levels and skill mix: midwives felt more positive and in control whilst caring for high-risk women when they were supported in the presence of a more experienced midwife equipped with knowledge in critical care.
17.(a) T(b) F(c) T(d) T(e) F
Explanations:
0.2–1.0% of pregnant women will require critical care during or after their pregnancy. Even in units with over 5000 deliveries per year less than 1 woman per week will require intensive care. Any published series are small and there is limited if any research available on the role of the obstetrician in critical care. It is difficult for all obstetricians and gynaecologists to have a complete understanding of invasive monitoring but equally it is difficult for intensivists to have a complete understanding of maternal physiology and pregnancy specific conditions. Maternal physiological changes can significantly alter the provision of critical care. It is necessary therefore to work as a team, each providing there own area of expertise. The role can be divided into the following areas: Leadership, clinical knowledge and skills, documentation, guideline development, risk management, debrief, audit and education.
18.(a) T(b) F(c) F(d) T(e) T
Explanations:
Only neuraxial blockade can truly abolish labour pain. In the absence of contraindications, regional analgesia may be offered early in labour and kept under close review to ensure analgesia is effective throughout. Effective regional analgesia minimises the cardiovascular effects of labour pain but a rapid onset of sympathetic blockade must be avoided. Sympathetic blockade causes vasodilatation and a reduced venous return, and may reduce cardiac output, especially in women whose compensatory mechanisms are obtunded by critical illness. These effects will be compounded by aorto-caval compression: the supine position should be scrupulously avoided and the parturient nursed in the sitting or lateral position.
19.(a) F(b) T(c) F(d) T(e) T
Explanations:
Absolute contraindications include: coagulopathy, severe systemic infection and raised intracranial pressure. The following are relative contraindications: hypovolaemia with cardiovascular instability; maternal pyrexia – may be performed after systemic antibiotic therapy commenced; fixed cardiac output states (e.g. severe aortic/mitral stenosis, hypertrophic obstructive cardiomyopathy).
20.(a) F(b) F(c) T(d) F(e) T
Explanations:
Uterotonics can have deleterious side effects in the cardiovascularly compromised parturient. Oxytocin is the most haemodynamically upsetting and may be associated with profound tachycardia and hypotension when administered as a 5 unit bolus, These effects are exaggerated by hypovolaemia and in those with compromised cardiac function. If syntocinon is necessary, bolus dosing should be avoided and the dose reduced, although some authorities argue that it should not be used at all in such patients. Ergometrine may cause hypertension and pulmonary vasoconstriction, and must be avoided in pulmonary hypertension. Carboprost (prostaglandin F2α), a potent smooth muscle constrictor, may cause bronchospasm, hypertension and rarely pulmonary oedema. The prophylactic placement of a uterine compression suture or tamponade balloon has been used to reduce the need for oxytocics.
21.(a) F(b) T(c) F(d) T(e) F
Explanations:
The recent and previous CEMACH reports on maternal death showed that 50% of maternal deaths involved substandard care. Around 0.2–0.9% of women will be admitted to critical care units. In a survey of BMFMS members, 60 units replied. 60% had a room dedicated to HDU/critical care. In a NPSA study, 11% of patients who died showed signs of deterioration that were not appreciated by the staff caring for them. Recognising those signs may have prevented death. Training for critical care receives little attention anywhere in the world. It is part of the curriculum for subspecialty training programmes around the world but there is often no formal training; it tends to be experiential.
22.(a) F(b) F(c) T(d) T(e) F
Explanations:
The recognition of critical illness has shown no improvement of any significance in recent years as evidenced by the recent NPSA and NICE reports in 2007. Fluid balance in the obstetric post–operative patient can be similar to the non-pregnant, however there are circumstances where this does not hold true. A pre-eclamptic patient is prone to fluid overload and as such fluid restriction is usually exercised post-op. Lack of awareness in the uninitiated can lead to pulmonary oedema. It is obvious that simply taking observations, does not equate to improved outcome. Sadly there is evidence to support this. The NPSA study (2007) shows that even when correct observations are made if the interpretation is incorrect, and/or the observations are made by untrained personnel then the outcome can be poor. Less than 1% of ITU admissions are obstetric. This means that exposure of critical care personnel to this patient group is going to be infrequent and thus experience in their care difficult to obtain. In a survey of obstetric units, 30% of midwifery training in HDU care was formal with the remainder informally trained. Whilst there is little evidence to support this, experience suggests that the confidence of a larger number of midwives is greatly enhanced by a formal training programme.
23.(a) T(b) F(c) F(d) F(e) F
Explanations:
In the most recent CEMACH report (2007) a “Top Ten” list of recommendations was made including, “all clinical staff caring for pregnant women learn from critical events and serious untoward incidents (SUIs)”. Such near misses can provide valuable lessons, show gaps in knowledge and allow protocols and guidelines to be strengthened. Another Top 10 was: “There is an urgent need for the routine use of a national obstetric early warning chart used for all obstetric women to help in the more timely recognition, treatment and referral of women who have, or are developing, a critical illness”. The answer is false however as the EWS should be available anywhere that the pregnant patient may access, such as critical care unit and A & E, and currently there is a paucity of data showing that there is improved outcome in obstetrics. Formalised protocols may help prevent adverse events, but only if backed up with adequate training of staff which should be multidisciplinary. The latter gives each member of the team a better idea of their role and the role of others. This will prevent confusion in the real situation leading to better patient care. There is little literature to back this up in the obstetric setting. A pilot programme was set up to attempt to develop a more formal curriculum for Maternal-Fetal Medicine fellows in the USA. The training included lectures, web based learning, scenario teaching and practical skills learnt in a human simulator laboratory. This led to an improvement in knowledge which is likely to improve outcome but there is currently no evidence that it has as yet.
24.(a) T(b) F(c) T(d) T(e) F
Explanations:
According to the Joint Commission sentinel event alert for perinatal deaths and injuries, competency/credentialing is among the top 4 reasons (out of 12) for unexpected perinatal death or injury. From 1995 to 2004 it was the 3rd leading cause and for 2005 it was tied for second along with patient assessment and environmental safety and security. From 1995 to 2004, staffing was the 6th leading cause of perinatal death or injury. However, in 2005, the Joint Commission reports that staffing fell to number 10. Communication failures and issues are consistently among the leading causes of adverse obstetric events, closed malpractice cases, and unexpected peri-natal deaths or injury. Communication issues have been found in 31% of closed malpractice claims. According to the Joint Commission, communication is the number 1 cause of peri-natal death or injury. From 1995 to 2004, communication issues were found in 80% of cases and in 2005 communication remained as the leading cause with over 70% of cases having communication issues. According to the same report, communication issues are the leading cause of operative sentinel events in 2005, the leading cause of medication errors and the leading cause of maternal deaths and injuries. For this reason creating and practising reliable mechanisms for communication are a major focus of teamwork training programs in healthcare. Leadership issues are frequently cited as major contributors to adverse obstetric events. According to the Joint Commission, leadership issues are the third leading factor associated with all sentinel events (not limited to obstetrics) in 2006, found in 40-50% of peri-natal deaths or injuries and almost 40% of medication errors. Leadership transitions are common in obstetrics. At many times critical care and/or labour and delivery nurses are leading medical care, but then there are transitions to obstetric providers and/or other medical providers. These times of hand-overs are particularly vulnerable times for transferring information and clarity on roles and responsibilities. Another issue quite common to critical care obstetrics is that many medical teams participate in the care of the patient. It is particularly important to have clarity on who is ultimately coordinating and directing the overall care for the patient. Though availability of information is important and in the top 10 contributors to sentinel events, it is not among the top 4 reasons for peri-natal death, maternal deaths, medication errors, or overall sentinel events according to the Joint Commission.
25.(a) F(b) F(c) F(d) F(e) T
Explanations:
A multidisciplinary approach is where physicians. nurses/midwives, pharmacists, respiratory therapists, and patients participate together in the rounding process. In this model, the hierarchy is flattened and all team members are encouraged to actively participate. This new approach has been shown to improve outcomes, reduce length of stay, and improve staff retention. Multidisciplinary rounds have been shown to reduce mortality, complications, and medical errors in a cardiac surgery unit and reduce ventilator associated complications and blood stream infections in medical ICUs. Multidisciplinary rounding did not reduce the incidence of urinary tract infections in the one study that examined this outcome. Multidisciplinary rounding has consistently been shown to reduce length of stay in intensive care units. Multidisciplinary rounding significantly decreased adverse events in the ICU resulting in a 21% reduction in cost per ICU discharge. Multidisciplinary rounding has consistently been found to significantly reduce adverse outcomes in medical and surgical ICUs.
26.(a) F(b) F(c) F(d) F(e) T
Explanations:
The Harvard Medical Practice study attempted to identify and quantify adverse events caused by medical error. The obstetric cohort had a 1.5% adverse events rate and the rate of negligence was 38.3%. A subsequent British study estimated 10.8% of hospital patients in the UK suffer an adverse event. Half of these are preventable and a third lead to moderate or greater disability or death. The adverse event rate in obstetrics was 4.0% with 71% of events being preventable. None of these studies provided data specific to critical care in obstetrics. The incidence of adverse events in critical care units has been reported to be 20.2%, with 55% being preventable, 13% life threatening or fatal and a further 11% potentially life threatening.
27.(a) T(b) F(c) F(d) T(e) T
Explanations:
The Safer patient Initiative has succeeded in achieving a 50% reduction in adverse events in each of the four pilot sites over two years. The model of change adopted by the Safer Patient Initiative is based on asking three key questions, using Langley's Model for Improvement. Small tests of change are performed in a rapid cycle to create a simple local measurement system that empowers local staff to change practice. In addition to supporting and developing leadership, it has the following five priority areas, all relevant to obstetric critical care: medicines management, infection prevention, intensive care risk assessment and response, medical device management and peri-operative care.
28.(a) T(b) T(c) F(d) F(e) T
Explanations:
Guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances and can improve quality of care by supplying the knowledge practitioners need to put evidence based medicine into practice. All obstetric critical care teams need local multidisciplinary guidelines. These must take into account the local situation and regional and national guidelines such as the NICE guidelines on care of the acutely ill in hospital. All guidelines need reviewing at suitable intervals to incorporate new evidence and issues identified through audit and adverse event reporting. There is evidence that compliance with guidelines does improve outcomes, so it is vital that the issues above are overcome. The Surviving Sepsis Campaign group has introduced the ‘sepsis care bundle’ into clinical practice with the goal of reducing mortality by 25% in five years. Implementing these sepsis bundles, Gao et al. found the noncompliant group had a more than twofold increase in hospital mortality.
29.(a) F(b) T(c) F(d) F(e) T
Explanations:
Tetracycline should be avoided in pregnancy due to it adverse fetal effects. A fall in the maternal PaO2 to below 65mmHg can compromise fetal oxygenation and therefore a maternal PaO2 of 60–70mmHg is targeted. Crystalloids and colloids have been shown to exhibit similar efficacy, however colloids are more expensive than crystalloids. The intravascular volume is typically contracted in sepsis and large volumes of fluid may be required to optimally resuscitate the patient. De-escalation is recommended as it helps reduce the occurrence of resistant bacteria.
30.(a) T(b) F(c) F(d) F(e) T
Explanations:
Blood transfusions and nasotracheal intubations definitely increase the risk of VAP. Enteral nutrition and nursing the patient head up reduces the risk of VAP. VAP occurs in intubated patients. Therefore non-invasive ventilation is not associated with the occurrence of VAP.
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