Qu’ils mangent de la brioche

During a trip to this amazing palace early last year, I was taken on a tour that included the room where Marie Antoinette gave birth. As princesses of the royal blood were not able to take the throne, the birth was public to ensure no substitution of the neonate at birth. Marie-Antoinette was married for 8 years prior to the birth of her first child, and her sister-in-law had already produced two male heirs to the throne. The pressure was on.

Her first born was, indeed, a girl and Marie Antoinette fainted on delivery. Historians have not come to a conclusion as to why this “faint” occurred, but many reason have been postulated and many of which have links to the primary learning objectives. It was thought the pressure to produce a male heir was too much and she fainted on the delivery of a female. She may have also fainted due to the heat from such a crowd in the room. Two enormous tapestry sheets surrounded her bed and fell on her immediately after delivery, due to the crush of people wanting to see the gender of the baby. And as the baby was born in 1778, there was no pain relief for delivery.

Whatever the reason, the management of this loss of consciousness was to open some windows and provide venesection therapy. Correlation and causation have been confused in history and these treatments were deemed successful.

Marie Antoinette went on to have four children, however her first child was the only one to reach adulthood. She was Queen of France for 20 minutes after her father-in-law abdicated and her husband (and cousin) took twenty minutes to sign the same document.

SS_OB 1.4 Describe the utero-placental circulation and the principles of placental physiology as related to placental gas exchange and regulation of placental blood flow.

Uteroplacental blood flow at term is approximately 1125mL/min TRUE/FALSE

The utero-placental arteries have alpha-adrenergic receptors. TRUE/FALSE

The greatest driving force for diffusion of oxygen from maternal to foetal blood is the Bohr effect. TRUE/FALSE

The Haldane effect facilitates oxygen transfer from the mother to the foetus. TRUE/FALSE

The foetus has foetal haemoglobin which has a greater affinity for oxygen than adult haemoglobin. TRUE/FALSE

Aortocaval compression

SS_OB 1.5 Describe the mechanism and consequences of aorta-caval compression in pregnancy

In supine hypotensive syndrome, blood still returns to the right heart through the epidural, azygos and vertebral veins. TRUE/FALSE

Supine hypotension is compensated by an increase in peripheral sympathetic activity. TRUE/FALSE

The blood pressure measured in the arms, is a reliable predictor of uterine and placental blood flow, when the patient is supine. TRUE/FALSE

Aortocaval compression can reduce uterine perfusion due to reduced uterine venous pressure. TRUE/FALSE

General anaesthesia has no effect on supine hypotensive syndrome. TRUE/FALSE


Obs, Obs, Baby.

SS_OB 1.6 Describe the changes in the anatomy of the maternal airway and their impact on airway management during anaesthesia.

SS_OB 1.1 Describe the physiological changes and their implications for anaesthesia that occur during pregnancy, labour and delivery.

The increased risk of airway bleeding during manipulation is primarily due to platelet dysfunction in pregnancy. TRUE/FALSE

Lung compliance decreases in pregnancy. TRUE/FALSE

Closing capacity increases during pregnancy. TRUE/FALSE

Oxygen consumption is increased at term, regardless of whether the patient is in labour or not. TRUE/FALSE

Airway oedema can occur due to venous engorgement from labour. TRUE/FALSE

Neonatal circulation

SB_OB 1.3 Describe the transition from foetal to neonatal circulation and the establishment of ventilation.

At birth, the circulation changes from parallel to in series. TRUE/FALSE

Delivery of the neonate causes a reduction in flow through the IVC to the right atrium. TRUE/FALSE

The newborn’s ventricle is less compliant than an adult’s due to a lower proportion of non contractile proteins in the myocardial cells. TRUE/FALSE

Pulmonary vascular resistance falls at birth due to decreasing pH TRUE/FALSE

The neonatal circulation can revert back to the pattern of foetal circulation if there is pulmonary vasoconstriction. TRUE/FALSE

A Primer for the Primary Examination

It can be difficult as a candidate without years of anaesthesia experience to appreciate the relative importance and clinical applications of different learning outcomes. One of the PLOOTD bloggers (who is of course incidentally an examiner) has therefore made this fantastic resource – A Primer for the Primary FANZCA examination. For each topic the depth of knowledge required is indicated, sources are recommended and some idea of the weighting in the exam is suggested. Many of the topics have useful musings from someone who has been an examiner for 12 years. Many of the topics also have links to some practice T/F questions with an idea of how difficult the writer feels they are.

This is going to be of most use to those who are sitting in August and beyond, but there’s a lot in there for those betwixt written and vivas too.

We think this resource is gold. Have a look and see what you think.

Drug Metabolism

BT_GS 1.11  Describe the mechanisms of hepatic and non-hepatic metabolism of drugs….


T / F   a phase 1 reaction exposes a polar group on the parent molecule, rendering it more water soluble

T / F  all phase 1 reactions are catalysed by the CYP450 enzymes

T / F  adding (conjugating) glucuronide to the parent molecule is an example of a phase 2 reaction

T / F  phase 2 reactions decrease the activity of the parent compound

T / F  CYP2D6 metabolises codeine to morphine – this enzyme is absent in 1% of caucasians


Is pharmacogenetic testing the “new frontier” of pharmacology? Your patients might have seen websites like this one from the Mayo clinic. Some patients are already coming to hospital with their “genetic printout” stating which drugs they should have!


BT_PO 1.82a  Outline basic cellular physiology, in particular …. energy production by metabolic processes in cells

BT_PO 1.83  Describe the physiological consequences of starvation


T / F  ketones are produced from the oxidation of free fatty acids

T / F  the important role of ketones is as an alternative fuel source to glucose for the brain – this decreases the protein catabolism which occurs via gluconeogenesis

T / F  lipolysis is stimulated by insulin, adrenaline, and cortisol

T / F  ketones provide a source of acetyl-CoA for use directly in the TCA cycle (structurally, ketones consist of actetyl groups)

T / F  in poorly nourished patients (frail elderly, alcoholics etc), a short period of fasting can induce starvation ketoacidosis


I’m not sure that taking ketone pills is a good idea!!

Now that you have thought about ketones….
i) find out if any of the glucometers in your hospital can also measure ketones (if not, how else could you diagnose ketosis?) 
ii) how would you treat starvation ketoacidosis in a non-diabetic?


IV Fluids – Crystalloids

IT_GS 1.5   Describe the chemical composition of crystalloids and colloids used in clinical practice and their effects when used in volume replacement


salt being produced at Shark Bay, Western Australia


T / F   the osmolarity of Hartmann’s solution is 255 mOsm/L, which is slightly lower than plasma

T / F   lactate is included in Hartmann’s because it gets metabolised to bicarbonate in the liver

T / F   5% glucose is a way of giving free water without causing haemolysis

T / F   5% glucose and “4% and a fifth” are iso-osmolar but hypo-tonic

T / F   if one litre of 0.9% saline is given rapidly IV, half of it will remain in the intravascular space after 4 hours

IV Fluids – Albumex

IT_GS 1.5   Describe the chemical composition of crystalloids and colloids used in clinical practice and their effects when used in volume replacement

stiff peaks2

The word albumin is derived from the Latin albus, meaning “white” (in reference to the white of an egg). Albumin is the most abundant egg white protein (although it’s ovalbumin – not quite the same as human serum albumin). Ever wondered why you can get “stiff peaks” to form when you beat egg whites? Click here to find out.

T / F   “Albumex 4” contains 4 g/L of albumin

T / F   Albumex is not a human blood product, because it is manufactured by recombinant DNA techniques

T / F   Albumex contains 150 mmol/L Na+ and 150 mmol/L Cl-

T / F   Albumex is rendered free of possible virus transmission by pasteurisation (heating to 60 degrees C for 10 hours)

T / F   the half life of albumin in the circulation is 48 hours