In the operation theatre, an emergency caesarean section under general anaesthesia is under way for a woman with severe pre-eclampsia whose platelet count is 48,000/µL. She has been on a magnesium sulphate infusion since an eclamptic seizure 6 hours ago, with knee jerks present, respiratory rate 16/min and urine output adequate. Her BP is 150/100 mmHg on IV labetalol, and the baby has been delivered. After a rapid sequence induction with propofol and succinylcholine and intubation, the anaesthetist plans rocuronium to keep her relaxed during surgery. What is the best plan for neuromuscular blockade?

Smaller doses titrated to train-of-four

Repeated succinylcholine boluses instead

Stop magnesium for the operation

The usual 0.6 mg/kg dose at fixed intervals

In established labour at 4 cm, a primigravida at 39 weeks with a previous deep vein thrombosis, on prophylactic enoxaparin 40 mg once daily through pregnancy, asks for an epidural. Her last dose was given 5 hours ago. Platelet count is 1.9 lakh/µL, she takes no antiplatelet drug and has no other bleeding risk. Her pain is severe, she is distressed, and the obstetrician expects delivery in 6-8 hours. Her husband asks why the anaesthetist is hesitating. Which plan is best for her analgesia?

Delay the epidural until 12 h after the dose

Delay the epidural until 24 h after the dose

Give protamine, then site the epidural

Site the epidural now with a small catheter

Thirty seconds after a test dose of 3 mL lignocaine 1.5% with adrenaline 1 in 200,000 through a newly sited lumbar epidural catheter in labour, the mother's heart rate rises from 88 to 120/min and she reports palpitations. She can still lift both legs normally and has no numbness. What is the best next step?

Withdraw and resite the catheter

Ten minutes after a 15 mL top-up of 0.5% bupivacaine through a labour epidural catheter for an emergency caesarean section, the mother says her hands feel weak and she cannot breathe properly; she then becomes drowsy. BP is 70/40 mmHg and HR 48/min, her pupils are normal in size and there are no convulsions or arrhythmia. The catheter had given good analgesia for 6 hours, but she had been hard to position and restless for the past hour. Before the top-up, no aspiration test was done through the catheter. What is the most likely cause?

Catheter migration into the CSF

Systemic local anaesthetic toxicity

Vasovagal reaction to the top-up

Pain management, day-care and obstetric anaesthesia

27 NEET-PG practice questions on Pain management, day-care and obstetric anaesthesia, part of Anaesthesia. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Hard
In the operation theatre, an emergency caesarean section under general anaesthesia is under way for a woman with severe pre-eclampsia whose platelet count is 48,000/µL. She has been on a magnesium sulphate infusion since an eclamptic seizure 6 hours ago, with knee jerks present, respiratory rate 16/min and urine output adequate. Her BP is 150/100 mmHg on IV labetalol, and the baby has been delivered. After a rapid sequence induction with propofol and succinylcholine and intubation, the anaesthetist plans rocuronium to keep her relaxed during surgery. What is the best plan for neuromuscular blockade?
1. ASmaller doses titrated to train-of-four
2. BRepeated succinylcholine boluses instead
3. CStop magnesium for the operation
4. DThe usual 0.6 mg/kg dose at fixed intervals
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Answer: A · Smaller doses titrated to train-of-four
A platelet count this low rules out neuraxial block, so general anaesthesia is used. Magnesium reduces acetylcholine release at the motor end-plate and reduces muscle sensitivity, so it markedly potentiates and prolongs non-depolarising relaxants. Use reduced doses titrated to a peripheral nerve stimulator, confirm full reversal before extubation, and continue magnesium for 24 hours after delivery for seizure prophylaxis. Key point: Magnesium potentiates non-depolarising relaxants: give smaller titrated doses with train-of-four monitoring.
- B: Repeated succinylcholine causes phase II block, bradycardia and hyperkalaemia.
- C: Stopping magnesium leaves her at risk of further eclamptic seizures.
- D: Standard fixed doses risk prolonged block and residual weakness after surgery.
Question 2 · Hard
PCA pump log overnight: morphine 1 mg per bolus, lockout 6 minutes, no background infusion and no hourly limit set. The patient, a man on the second day after a laparotomy for perforated duodenal ulcer, was restless and groaning on the night round; his abdomen is now more distended and tender. Between 1 a.m. and 2 a.m. he pressed the button 38 times, and the nurse has paged the duty doctor. What is the most morphine he could have received in that hour?
1. A38 mg
2. B10 mg
3. C19 mg
4. D6 mg
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Answer: B · 10 mg
With a 6-minute lockout the pump can deliver at most one bolus every 6 minutes, that is 60 / 6 = 10 boluses an hour, or 10 mg; the other 28 presses were unsuccessful demands. Many unsuccessful demands mean the patient's pain is poorly controlled, so the regimen and the cause of pain should be reviewed rather than simply increasing the bolus. Key point: Maximum PCA dose per hour = bolus x (60 / lockout in minutes); many failed demands signal poor control.
- A: 38 mg would ignore the lockout; only 10 presses can be delivered.
- C: 19 mg has no basis in the pump settings.
- D: 6 mg confuses the lockout minutes with the number of doses.
Question 3 · Hard
In established labour at 4 cm, a primigravida at 39 weeks with a previous deep vein thrombosis, on prophylactic enoxaparin 40 mg once daily through pregnancy, asks for an epidural. Her last dose was given 5 hours ago. Platelet count is 1.9 lakh/µL, she takes no antiplatelet drug and has no other bleeding risk. Her pain is severe, she is distressed, and the obstetrician expects delivery in 6-8 hours. Her husband asks why the anaesthetist is hesitating. Which plan is best for her analgesia?
1. ADelay the epidural until 12 h after the dose
2. BDelay the epidural until 24 h after the dose
3. CGive protamine, then site the epidural
4. DSite the epidural now with a small catheter
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Answer: A · Delay the epidural until 12 h after the dose
Neuraxial puncture within 12 hours of a prophylactic LMWH dose raises the risk of a spinal epidural haematoma, which can cause paraplegia. The block is delayed until 12 hours after the last prophylactic dose (24 hours after a therapeutic dose), with IV opioid or remifentanil PCA meanwhile, and the next dose is given at least 4 hours after catheter removal. Key point: Neuraxial block on LMWH: wait 12 hours after a prophylactic dose and 24 hours after a therapeutic dose.
- B: 24 hours applies to therapeutic doses; she is on a prophylactic dose.
- C: Protamine only partly reverses LMWH and is not used to permit neuraxial block.
- D: Catheter size does not remove the haematoma risk within 12 hours.
Question 4 · Medium
Thirty seconds after a test dose of 3 mL lignocaine 1.5% with adrenaline 1 in 200,000 through a newly sited lumbar epidural catheter in labour, the mother's heart rate rises from 88 to 120/min and she reports palpitations. She can still lift both legs normally and has no numbness. What is the best next step?
1. AInject 10 mL saline and repeat
2. BGive the full loading dose
3. CWithdraw and resite the catheter
4. DStart a bupivacaine infusion
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Answer: C · Withdraw and resite the catheter
The test dose has two parts: 15 microgram of adrenaline that raises the heart rate by 20 or more beats a minute within a minute if the catheter is in a vein, and lignocaine that causes a rapid motor block if it is intrathecal. A sudden tachycardia without motor block means intravascular placement, so further local anaesthetic through it risks systemic toxicity. Key point: Tachycardia after an adrenaline test dose means an intravenous epidural catheter: withdraw and resite it.
- A: Flushing with saline does not move the catheter out of the vein.
- B: Loading through an intravascular catheter risks local anaesthetic toxicity.
- D: An infusion would also run into the vein.
Question 5 · Hard
Ten minutes after a 15 mL top-up of 0.5% bupivacaine through a labour epidural catheter for an emergency caesarean section, the mother says her hands feel weak and she cannot breathe properly; she then becomes drowsy. BP is 70/40 mmHg and HR 48/min, her pupils are normal in size and there are no convulsions or arrhythmia. The catheter had given good analgesia for 6 hours, but she had been hard to position and restless for the past hour. Before the top-up, no aspiration test was done through the catheter. What is the most likely cause?
1. AAmniotic fluid embolism
2. BSystemic local anaesthetic toxicity
3. CVasovagal reaction to the top-up
4. DCatheter migration into the CSF
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Answer: D · Catheter migration into the CSF
An epidural catheter can migrate into the subarachnoid space, so a full epidural dose given intrathecally causes a high or total spinal: ascending block with hand weakness (C6-T1), dyspnoea, hypotension, bradycardia from block of the cardioaccelerator fibres (T1-T4) and loss of consciousness. Treatment is airway support with intubation, vasopressors and atropine, left uterine displacement and prompt delivery. Key point: Rapid ascending block with hand weakness, bradycardia and apnoea after an epidural top-up is a high spinal from catheter migration.
- A: Amniotic fluid embolism gives sudden hypoxia, collapse and coagulopathy without hand weakness.
- B: Systemic toxicity starts with perioral numbness, tinnitus and seizures, not ascending motor block.
- C: A vasovagal attack does not produce weakness of the hands and breathing.
Question 6 · Medium
In the labour room of a district hospital, a primigravida at 5 cm cervical dilatation requests an epidural. After the catheter is sited and a test dose is negative, the anaesthetist wants good pain relief while she can still move her legs and push in the second stage. Which solution is best for maintenance?
1. ABupivacaine 0.5% with adrenaline 5 microgram/mL
2. BEpidural morphine 5 mg alone
3. CLignocaine 2% with adrenaline
4. DBupivacaine 0.1% with fentanyl 2 microgram/mL
Answer and explanation in LearnFree account
Question 7 · Medium
Listed for day-care inguinal hernia repair under general anaesthesia, an ex-preterm baby born at 30 weeks of gestation is now 8 weeks old (38 weeks post-conceptional age). He is feeding well, gaining weight and has no current respiratory illness. Both parents are keen to take him home the same evening. What is the most appropriate plan?
1. ADischarge 4 hours after surgery
2. BAdmit overnight with apnoea monitoring
3. CDischarge once feeding well
4. DPostpone surgery until age 1 year
Answer and explanation in LearnFree account
Question 8 · Hard
As the anaesthetist planning analgesia for an open appendicectomy, you see a woman with asthma and nasal polyps who once wheezed badly after ibuprofen, and who also has chronic kidney disease with a serum creatinine of 2.4 mg/dL (normal 0.6-1.1). She has no liver disease and is not on anticoagulants. She is anxious about nausea and itching after an earlier operation with morphine, and she wants to walk on the first post-operative day. Which post-operative analgesic plan is the most suitable?
1. AParacetamol, TAP block, rescue fentanyl
2. BKetorolac with a morphine PCA
3. CPethidine PCA as the only drug
4. DCelecoxib with regular paracetamol
Answer and explanation in LearnFree account
Question 9 · Medium
Three minutes after a spinal anaesthetic for an elective caesarean section, with the table tilted to the left, the mother's BP falls from 124/78 to 88/50 mmHg; her heart rate is 96/min and she feels nauseated. Crystalloid co-loading is running. According to the 2018 international consensus, which vasopressor is the first choice?
1. AMephentermine
2. BEphedrine
3. CAdrenaline
4. DPhenylephrine
Answer and explanation in LearnFree account
Question 10 · Medium
Despite 48 hours of bed rest, fluids, paracetamol and caffeine, a mother still has a severe postural headache after an accidental dural puncture with a 16G Tuohy needle during her labour epidural. She cannot sit up to feed her baby. There is no fever and the neurological examination is normal. What is the most effective treatment?
1. ATherapeutic lumbar drain
2. BIV sumatriptan injection
3. CEpidural blood patch
4. DIntrathecal saline infusion
Answer and explanation in LearnFree account
Question 11 · Medium
Sedation score 3 (difficult to rouse) is recorded at 3 a.m. by the ward nurse in a woman using morphine PCA after a total knee replacement. Her RR is 7/min, SpO2 86% on room air, pupils are pinpoint and BP is 112/70 mmHg. Her daughter admits pressing the button for her so she would sleep well. After stopping the PCA and giving oxygen, what is the next step?
1. AIV flumazenil 0.5 mg
2. BIV naloxone in small repeated doses
3. CIV doxapram infusion
4. DRestart PCA with a longer lockout time
Answer and explanation in LearnFree account
Question 12 · Easy
A stellate ganglion block for complex regional pain syndrome of the arm is judged successful when which sign appears on the same side?
1. AHorner syndrome
2. BHoarseness of voice
3. CWeakness of the arm
4. DRaised hemidiaphragm
Answer and explanation in LearnFree account
Question 13 · Medium
A man on maintenance haemodialysis for diabetic kidney disease needs IV opioid analgesia after an emergency laparotomy. After morphine for an earlier operation he stayed drowsy for 2 days. Which option explains this and gives the preferred opioid now?
1. AMorphine is not metabolised; use codeine
2. BNormorphine accumulates; use pethidine
3. CMorphine-3-glucuronide sedates; use tramadol
4. DMorphine-6-glucuronide accumulates; use fentanyl
Answer and explanation in LearnFree account
Question 14 · Easy
On the second day after a caesarean section under spinal anaesthesia, a mother has a frontal and occipital headache with neck stiffness that is severe when she sits up to feed her baby and eases within minutes of lying flat. BP is 118/76 mmHg, she has no fever and there are no focal signs. What is the mechanism of her headache?
1. ARaised intracranial pressure from oedema
2. BLow CSF pressure from a dural leak
3. CCerebral vasoconstriction from pre-eclampsia
4. DChemical meningitis from the local anaesthetic
Answer and explanation in LearnFree account
Question 15 · Hard
Post-herpetic pain persists 4 months after shingles over the left T6 dermatome in a retired tailor. It is burning and constant, and even the touch of his shirt is painful. Paracetamol does not help. He has benign prostatic hyperplasia with a poor urinary stream, narrow-angle glaucoma under follow-up with an ophthalmologist, and chronic kidney disease with an eGFR of 45 mL/min/1.73 m2. He lives alone, is worried about falls and has already lost sleep for weeks because of the pain. Which oral drug is the most suitable first choice?
1. ATramadol with paracetamol
2. BPregabalin, renally adjusted
3. CCarbamazepine 200 mg twice daily
4. DAmitriptyline at bedtime
Answer and explanation in LearnFree account
Question 16 · Medium
A day-care unit audits its discharge policy after dental extractions and knee arthroscopies under general anaesthesia. Which are accepted requirements before discharge home? 1. Every patient, whatever the procedure, must pass urine first. 2. A responsible adult escorts the patient home. 3. A Post-Anaesthetic Discharge Scoring System (PADSS) score of 9 or more. 4. Every patient must drink fluids without vomiting. Select the correct option.
1. A3 and 4 only
2. B2 and 3 only
3. C1, 2, 3 and 4
4. D1, 2 and 3 only
Answer and explanation in LearnFree account
Question 17 · Medium
Severe epigastric pain radiating to the back persists in a man with unresectable carcinoma of the head of the pancreas despite oral morphine 120 mg a day, which is also making him drowsy and constipated. The palliative care team arranges a neurolytic coeliac plexus block with alcohol under CT guidance. Which effects are most expected in the first 48 hours?
1. AHorner syndrome on the right
2. BPostural hypotension and diarrhoea
3. CUrinary retention
4. DParaplegia from spinal cord infarction
Answer and explanation in LearnFree account
Question 18 · Medium
Electric-shock-like pains lasting seconds shoot across the right cheek and upper lip of a retired clerk many times a day, set off by brushing his teeth or a cold breeze. Between attacks he is pain free, the neurological examination including corneal reflex is normal and MRI shows no tumour or plaque. Which drug is the first choice?
1. ACarbamazepine
2. BOral morphine
3. CAmitriptyline
4. DPregabalin
Answer and explanation in LearnFree account
Question 19 · Easy
After day-care surgery under general anaesthesia, a patient should be advised not to drive for at least how long?
1. A12 hours
2. B24 hours
3. C6 hours
4. D72 hours
Answer and explanation in LearnFree account
Question 20 · Easy
After laparoscopic cholecystectomy, paracetamol, an NSAID, port-site local anaesthetic and rescue opioid are combined. The main aim of this multimodal approach is:
1. AFaster gastric emptying after surgery
2. BBetter analgesia with less opioid
3. CTotal avoidance of any opioid use
4. DLonger action of the local anaesthetic
Answer and explanation in LearnFree account
Question 21 · Medium
On the gynaecology ward, the night after an open abdominal hysterectomy, a 58 kg woman who has never taken opioids is to start IV morphine patient-controlled analgesia. Her kidney function is normal, she has no sleep apnoea and she is not on sedatives. Which pump program is the safest appropriate starting choice?
1. A1 mg bolus, 1-min lockout, no background
2. B5 mg bolus, 30-min lockout, no background
3. C1 mg bolus, 5-min lockout, no background
4. D1 mg bolus, 5-min lockout, plus 2 mg/h background
Answer and explanation in LearnFree account
Question 22 · Medium
A woman on sertraline 100 mg daily for depression is given tramadol 100 mg 8-hourly after a fracture fixation. On the second day she is agitated, sweating and tremulous, with temperature 38.4 °C, HR 118/min, brisk reflexes and inducible ankle clonus. Her pupils are dilated. What is the most likely cause?
1. AMalignant hyperthermia
2. BNeuroleptic malignant syndrome
3. COpioid withdrawal
4. DSerotonin syndrome
Answer and explanation in LearnFree account
Question 23 · Easy
The acute pain nurse explains a morphine patient-controlled analgesia pump to a man before his open hernia repair: each press gives 1 mg, and the pump then ignores further presses for 5 minutes. What is the main purpose of this 5-minute period?
1. APrevents opioid tolerance developing
2. BConserves the drug in the syringe
3. CStops air entering the IV line
4. DAllows each dose to take effect
Answer and explanation in LearnFree account
Question 24 · Medium
In the labour room at 2 a.m., a category 2 caesarean section under general anaesthesia is planned because the mother refuses a spinal; she ate a full meal 3 hours ago. IV access is in place and the operation will start in 5 minutes. Which drug, given just before induction, raises gastric pH immediately?
1. AIV famotidine
2. BSodium citrate
3. COral pantoprazole
4. DIV metoclopramide
Answer and explanation in LearnFree account
Question 25 · Easy
Pain of the first stage of labour is carried by visceral afferents entering the spinal cord at which segments?
1. AS2 to S4
2. BT10 to L1
3. CL2 to L4
4. DT6 to T8
Answer and explanation in LearnFree account

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Pain management, day-care and obstetric anaesthesia

A stellate ganglion block for complex regional pain syndrome of the arm is judged successful when which sign appears on the same side?

A man on maintenance haemodialysis for diabetic kidney disease needs IV opioid analgesia after an emergency laparotomy. After morphine for an earlier operation he stayed drowsy for 2 days. Which option explains this and gives the preferred opioid now?

After day-care surgery under general anaesthesia, a patient should be advised not to drive for at least how long?

After laparoscopic cholecystectomy, paracetamol, an NSAID, port-site local anaesthetic and rescue opioid are combined. The main aim of this multimodal approach is:

The acute pain nurse explains a morphine patient-controlled analgesia pump to a man before his open hernia repair: each press gives 1 mg, and the pump then ignores further presses for 5 minutes. What is the main purpose of this 5-minute period?

Pain of the first stage of labour is carried by visceral afferents entering the spinal cord at which segments?