For the mothers

I know it came up in the April 2008 SAQs, but it's still a hot topic so here it is again:

CEMACH 2003-2005 Summary


Definition
- Confidential Enquiries into Maternal Deaths.
- The longest running "Gold Standard" audit in the world. First Report covered 1952-54
- Triennial report published by DOH looking into all maternal deaths in UK
- Changed title from “Why Mothers Die” to “Saving Mothers’ Lives”.
- All maternal deaths: 14 per 100000 maternities (no statistically significant change).
- Direct maternal mortality: slight rise (not statistically significant).


Causes of death:
- Direct: deaths of women while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not accidental or incidental causes.
- Indirect: deaths resulting from previous existing disease, or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by the physiological effects of pregnancy.
- Late: deaths occurring between 42 days and one year after the end of pregnancy


Risk Factors contributing to maternal death
(Essentially the same as the lack of decline of maternal mortality)

- Lack of preconception care i.e counselling & support especially for serious physical/mental comorbidities, obesity, assisted reproduction/fertility, and identification of vulnerable/high risk mothers.
- Lack of access to antenatal care
- Migrants (poorer overall health, no medical review, genital mutilation)
- Increasing age of mothers
- Increasing incidence of obese mothers
- Increasing incidence of comorbidities e.g. DM/CVS disease
- Poor lifestyle e.g. smoking/drinking/drugs


Commonest direct causes of maternal death

1) Thromboembolism (again)
=2) Pre-eclampsia/sepsis
4) Amniotic fluid embolism
=5) Haemorrhage/early pregnancy

- Increased numbers of: pre-eclampsia, genital tract sepsis/trauma + inexplicable rise in amniotic fluid embolism.
- Decreased haemorrhage/early pregnancy/ectopic.
- Nil of above: statistically significant.

Commonest indirect cause of maternal death
- Cardiac disease (less healthy diets, smoking, alcohol and the growing epidemic of obesity).

Anaesthetics
- 150 cases reviewed: direct or indirect cause of death also having anaesthetic

Direct anaesthetic deaths:
- 6 deaths – (4.5%) 0.28 per 100000 maternities. Same as previous triennium.
- All but one: Caucasian.
- 4/6: obese (2 were morbidly obese: BMI > 35)

Cases
1) Post-op bronchospasm & resp failure: obese asthmatic lady – failed reintubation during recovery post laparascopic surgery for ectopic pregnancy. Irreversible cardiac arrest.

2) Obese lady, early pregnancy, trainee anaesthetist. High-dose opiate given prior to extubation. In recovery developed respiratory difficulties. Inadequate ventilation, bradycardia, cardiac arrest.

3) Morbidly obese asthmatic lady, elective LSCS, spinal anaesthesia. Post-op agitation and SOB. Fatal cardiac arrest on post-op ward with inadequate resuscitation equipment.

4) Low-dose infusion epidural during labour & forceps delivery. PPH + IVI + syntocinon infusions. Grand mal convulsion + VF arrest – unable to resuscitate. Given 150mls 0.1% bupivacaine IV.

5) Lady with pectus excavatum in mid-pregnancy: â foetal movements, fulminant PET, & HELLP. Hypertensive, hyperreflexic, oliguric, & abnormal LFTs – given labetalol, Mg, & hydralazine. For urgent LSCS: RIJ cannulation unsuccessful but subclavian cannulation successful on the second attempt. Cardiac arrest shortly afterwards – large right haemothorax.

6) Obese woman with longstanding renal problems requiring nephrectomy. Had premature labour and delivery. A few weeks later, she was admitted with fever, loin pain, and ileofemoral venous thrombosis. Planned for drainage of septic focus from remaining kidney under U/S guidance. Pt refused LA and suffered an irreversible cardiac arrest during GA.

Indirect Anaesthetic Deaths

-Further 31 cases where poor perioperative anaesthetic management may have contributed to outcome

- Failure to recognise serious illness

- Poor management of haemorrhage (including syntocinon use): Less than optimum anaesthetic management contributed to many of the 17 maternal deaths from haemorrhage (12 died from PPH).

- Sepsis: Poor anaesthetic management/resuscitation was thought to have contributed to 10 maternal deaths from sepsis (usually failure to appreciate seriousness of maternal condition).

- Pre-eclampsia/eclampsia: 4 women died in relation to poor anaesthetic management (usually related to poor control of systolic blood pressure at time of LSCS/post-operatively)

- Management of obese pregnant women

- Quality of in-house hospital Trust enquiries into serious untoward incidents including maternal deaths: some reports of internal hospital enquiries sent to CEMACH were lacking in insight, improperly conducted, did not include clinicians from relevant specialties, or included clinicians involved directly with the maternal death (potential bias).

More Reading Material

Previous SAQ papers can be downloaded from the RCOA website here.

AnaesthesiaUK has many many past questions divided into various sections from here and here.
I have grouped all the questions according to SAQ, Long Cases, Short Cases, and Basic Sciences.

I would also look at the CEACCP supplements from 2007-8 that come with the BJA every other month. These topical subjects are excellent SAQ/SOE fodder. If you haven't got hard copies, they can be downloaded here, although you will need to sign in with your BJA subscription details.

The Bulletins from the RCOA can also be a useful source of information, again these can be downloaded from here.

Review articles from the BJA provide exam material too, using archives from 2007 and 2008.

Similarly, review articles from Anaesthesia, using archives from 2007 and 2008. Again, you will need membership details to access these.

Hope this provides some needed direction; there's still more to come!!

Buy a library

There are certain essential materials in my opinion which are invaluable for this exam:

Download a copy of the syllabus and use this to break your revision up into topics

Order a copy of the new guide to the FRCA Final Examination. As with the Primary version, this has examples of questions from all sections of the exam. The MCQ section is particularly useful as it is taken from the actual college bank and some do appear in the exam.

Opinion is divided as to whether to use a large textbook or not e.g. Aitkenhead, Pinnock, Hutton etc. This is a personal opinion and one which can be decided by previous experience for Primary and browsing before trying. Candidates will need to purchase/borrow some specialist text-books - many can be ordered from AnaesthesiaUK here or from Amazon. Here is a list I found useful:

General
"Companion to Clinical Anaesthesia Exams (FRCA Study Guides)"Charlie Corke
"Clinical Notes for the FRCA (FRCA Study Guides)"Charles Deakin

MCQ
"Final FRCA: Multiple Choice Questions (FRCA Study Guides)"Michael D. Brunner
"QBase Anaesthesia: MCQs for the Final FRCA v. 5"Edward Hammond
"MCQs for the Final FRCA"Khaled Elfituri
"MCQ's in Anaesthesia (FRCA Study Guides)"A. Ganado
"QBase Anaesthesia: MCQs for the Anaesthesia Final FRCA v. 2 (QBase)"Mark Blunt
"FRCA: MCQs for the Final FRCA: Saunders Self Assessment Series: MCQs for the Final FRCA (FRCA Study Guides)"Karen Henderson
"Practice MCQ's for the Final FRCA (FRCA Study Guides)"Jon Hardman

SAQ
"Anaesthesia & Critical Care" Chris Dodds & Neil Soni
"Short Answer Questions and MCQs in Anaesthesia and Intensive Care"Peter Murphy
"Short Answer Questions in Anaesthesia"Simon Bricker;
"Final F.R.C.A.: Short Answer Questions"J. Nickells

SOE
"The Anaesthesia Science Viva Book" Simon Bricker
"The Clinical Anaesthesia Viva Book"Simon J. Mills

Of course, the A to Z comes in handy too.

Let's have a date

OK, there is just under four months until the MCQ/SAQ paper which is on Tuesday 21st October. Hopefully people have started to revise by now, the big decision of whether to take the exam comes shortly as the opening date for entry is this Friday 4th July. We have until Tuesday 9th September to get the application (& money!) in - probably best not leave until the Monday!

Quite importantly, the paper is set on Tuesday 16th September, meaning that any topical subjects generally for the SAQ and SOE are fair game in journals up to September 2008. I will highlight these as we get nearer the time.

A New Beginning

Congratulations to everyone who passed the exam last week - it was no mean feat at all! Unfortunately, I was not successful for a number of reasons; I got a 1+ in the MCQ section which left me on a handicap going into the vivas. I got 2's in the SAQ and Clinical Viva, but had a major hiccup in the Science Viva - I got asked about the intercostal nerve etc and started off OK but then completely blanked. It spiralled downwards from there unfortunately. I thought I had rescued it in pharmacology, talking about conscious sedation & drugs etc, physiology was OK on oxygen delivery, but I appeared to struggle on physics and the Venturi effect of all things. It was a good example of letting an earlier bad section get to me. In hindsight, I should have done more MCQs!! It has been one of the toughest weeks of my career so far, but thanks to some great girlfriend/family/friend/work colleague support, I'm doing OK.

I decided that, despite having been an extremely public humiliation via this blog's reasonably wide stretching and advertising on AnaesthesiaUK, I would carry on blogging. Firstly, I hope it will give heart to others who weren't successfull this time, that they aren't alone in suffering; and secondly, because I know the information I have shared on this blog has helped people - and I hope to continue to do the same for the next batch of people.

You can read my previous efforts in their entirety at an alternative blogsite (I will transfer some relevant stuff from there): http://didntpassthefinal.blogspot.com.

For more excellent advice on how to pass this exam by someone who did pass, visit Exam Intelligence