Obsgynaecritcare Roger Browning - Anaesthetist

You receive a page from labour ward.







A woman at 35/40 weeks gestation has just arrived in the hospital very distressed in a lot of pain. A quick bedside ultrasound by the obstetric team has unfortunately demonstrated a large abruption and fetal death in utero. She is contracting strongly and beside herself in pain, the team would like you to come down and place an epidural for analgesia. The team are hoping she will deliver vaginally in the next few hours.







What is your approach in this situation?







Join Graeme and I as we discuss this complex and challenging clinical condition and the coagulopathy that can occasionally occur.







Here is a link to cases we have had in the past here at KEMH in the ROTEM Real Cases Discussed section:







Case 6 - Abruption and fetal death in utero







Case 11 - Abruption and severe coagulopathy







References







Coagulopathy and placental abruption: changing management with ROTEM-guided fibrinogen concentrate therapy 2015 Liverpool Womens Hospital - this is not open access but available through the ANZCA library or your hospital library. It contains 4 very interesting case reports







Fibrinolytic and thrombotic DIC an explanation 2023 - This paper explains how there are two types of DIC one predominantly causing microvascular thrombosis and eventually factor depletion. The second which is possibly the mechanism seen in some abruptions is massive activation of fibrinolysis and fibrinogenolysis. WARNING this paper is highly technical!

You recline your seat back, adjust your neck pillow, eye mask and close your eyes. Finally you are about to have that well earned nap. It was exhausting having to get up at 3am to head to the airport for this unpleasantly scheduled early flight. As your mind drifts towards sleep your thoughts are interrupted by a loud announcement by one of the cabin crew.







"If anyone with medical experience is onboard can you please make yourselves known to the cabin crew?"







You gently pull your mask aside and see two cabin crew applying oxygen and crouching over a passenger lying supine at the front of the aircraft. You quietly glance around the aircraft - no one else seems to have volunteered to help........







If you have any medical, nursing or paramedical training and you occasionally fly on an aeroplane then this talk could well be relevant to you!







This week I am joined by Ilan, one of our anaesthetic fellows and the current education fellow. Ilan is also a licensed pilot and has an interest in inflight medical emergencies and their management. Join us as we discuss the physiology, epidemiology, legal issues and share some anecdotes on this fascinating topic.







Thanks Ilan!































References









https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3789915/ - In flight medical emergencies Western J Emerg Medicine 2013







https://jamanetwork.com/journals/jama/article-abstract/2719313 - In flight medical emergencies JAMA 2018







https://onepagericu.com/in-flight-medical?rq=flight -







https://www.casa.gov.au/ - Australian Aviation Governing Authority where all the legal requirements for flight operations in Australia can be found







https://insightplus.mja.com.au/2017/39/what-is-my-duty-to-assist-in-emergency/ - Duty to Assist in MJA







https://www1.racgp.org.au/newsgp/professional/medical-good-samaritans-and-the-law-what-gps-need

You are called to review a woman in labour ward. When you arrive you are told her epidural is no longer working. The epidural was placed by a colleague 5 hours ago and was working well. However in the last 20-30 minutes she has developed breakthrough pain despite a top up and pressing the PCEA a few times. You look at her back and the epidural dressing looks fine - no obvious explanation there.







Upon further questioning you are told that she had a caesarean in her previous pregnancy and she is attempting a VBAC. She tells you that since you arrived in the room the pain has changed. Now it is constant and she has developed pain in her shoulder. Suddenly the CTG deteriorates and within a few minutes the team are calling a code blue caesarean to theatre.....This is recollection of a real case from an evening shift a few years ago.







As you can probably guess this week we are discussing the important and somewhat scary topic of uterine rupture.







This week we are joined to discuss this topic by Dr David Owen. David is a senior obstetrician, who previous to WA worked at Liverpool Women's Hospital and was a psychiatrist in a previous life.







Thanks David!







References







Uterine Rupture: A Seven Year Review at a Tertiary Care Hospital in New Delhi, India







Tocogram characteristics of uterine rupture: a systematic review

A maternal death is always a tragic event for the mother, the child, the family and society at large. Unfortunately in some parts of the globe this is still a much too common event. Luckily for those of us living in higher resource countries it has now become relatively rare.







This week Matt and I sat down together to discuss the history of maternal mortality reporting, and all the useful knowledge we have been able to learn over the years from these important resources.







What are direct, indirect and coincidental maternal deaths? We touch on some aspects of the recent Australian reports and then go into depth on the long history of the UK reports which have many strengths such as their national funding, compulsory reporting, anonymous nature and very long history.







Thanks Matt







References







Maternal Mortality Report Australia







Maternal Mortality World Health Organisation WHO







MBRRACE-UK Maternal mortality reports UK







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As the duty anaesthetist you are called down to the antenatal clinic by the obstetric team to see a pregnant woman with achondroplasia who is booked to deliver in your hospital.







What are the anaesthetic issues which can arise in this condition? What evidence is there in the literature for the optimal anaesthetic techniques? What will you discuss with this woman and how will you counsel her?







Join Declan and I as we discuss the anaesthetic issues of this relatively rare but sometimes challenging condition...







References







Dumitrascu CI, Eneh PN, Keim AA, Kraus MB, Sharpe EE. Anesthetic management of parturients with achondroplasia: a case series. Proc (Bayl Univ Med Cent). 2023 Dec 20;37(1):63-68. doi: 10.1080/08998280.2023.2261084. PMID: 38173994; PMCID: PMC10761160.







Lange, E.M.S., Toledo, P., Stariha, J. et al. Anesthetic management for Cesarean delivery in parturients with a diagnosis of dwarfism. Can J Anesth/J Can Anesth 63, 945–951 (2016). https://doi.org/10.1007/s12630-016-0671-5







15 Ways Pregnancy Is Different For Little People - Good Lay Person Website

You are called to a code blue on the postnatal ward. A 28 yr old female who is 1 day post a non elective caesarean section has just had a witnessed convulsion lasting 1-2 min. She has now regained consciousness but seems a little confused and is complaining that she "has lost vision in both of her eyes". Her BP is 180/100, and all other vital signs are normal.







What is this most likely to be? What is your differential diagnosis (what things do you not want to miss)? What investigations would you like done?







This turns out to be an episode of eclampsia and PRES (posterior reversible encephalopathy syndrome).







What is PRES? What are it's radiological features and what is the mechanism which leads to this disorder?







Join Graeme and I as we discuss this uncommon but fascinating condition.







References







Gewirtz AN, Gao V, Parauda SC, Robbins MS. Posterior Reversible Encephalopathy Syndrome. Curr Pain Headache Rep. 2021 Feb 25;25(3):19. doi: 10.1007/s11916-020-00932-1. PMID: 33630183; PMCID: PMC7905767.







Marcoccia E, Piccioni MG, Schiavi MC, Colagiovanni V, Zannini I, Musella A, Visentin VS, Vena F, Masselli G, Monti M, Perrone G, Panici PB, Brunelli R. Postpartum Posterior Reversible Encephalopathy Syndrome (PRES): Three Case Reports and Literature Review. Case Rep Obstet Gynecol. 2019 Jan 27;2019:9527632. doi: 10.1155/2019/9527632. PMID: 30809401; PMCID: PMC6369475.