Obsgynaecritcare

(*Fictitious case) You are contacted by the ultrasound department - they have just completed a formal scan on an urgent referral and want to discuss their findings with you urgently. A 34yr old woman was admitted overnight with some PV bleeding at 32 weeks. She has had 2 previous caesareans and on the scan they have found a low lying anterior placenta which overlies the previous scar and concerningly there appears to be ultrasonographic evidence of accreta (vascular lacunae) and possibly doppler evidence of large vessels indicating invasion of the bladder (percreta). This condition quite rightly strikes fear into the heart of surgeon and anaesthetist alike - primarily because of the risk of catastrophic torrential haemorrhage. What are the principles of managing someone with placenta percreta? Hi Everyone, This week on the podcast I am joined again by my Colleague Graeme Johnson where we discuss the perioperative and anaesthetic management of the patient with a morbidly adherent placenta. Useful links

(*Fictitious case) A 32 yr old pregnant woman with insulin dependent diabetes presents to a regional hospital in WA at 27 weeks gestation, with probable premature rupture of her membranes, threatened preterm labour and a low grade fever. She is given a dose of celestone (betamethasone) intramuscularly, some nifedipine for tocoloysis and has an urgent areomedical transfer organised. During the flight she has a salbutamol infusion to provide further tocolysis and minimise the risk of delivery of a 27 week foetus in the back of the plane which the retrieval team are very keen to avoid! On arrival at your tertiary hospital she is febrile (T 38.4) but the most striking thing noted is the fact she is breathing very heavily but yet has clear lungs and normal SpO2 of 99%. The team assessing her do some blood tests including an arterial blood gas and obtain the following results: pH 7.26, pCO2 16, pO2 128, HCO3 7.5, Na 141, K 4.8, Cl 101, Gluc 19.0, Urea 8.1, Crn 0.09 Urine analysis: Glucose 4+, Ketones 1+ What

Hi everyone, This weeks post is part 2 of the 5th in my mini series on patient blood management in obstetrics and gynaecology. We discuss some of the strategies we can use to avoid or treat excessive bleeding which can occur during gynaecological surgery or obstetric haemorrhage - this week focussing on anaesthetic / pharmacological and coagulation management strategies. I am told by some trusted mentors that most podcast (or vodcast) listeners or viewers are time poor & have relatively shortish attention spans such that around 15min is the "sweet spot" for most of us. So based on that this talk is only meant to be a summary - I do hope to inspire you to go away and think about some of these techniques if they catch your interest. Do some more learning and research on your own. Some people have built whole careers around some of these different techniques / strategies! I will hopefully come back at some stage and do a "deep dive" to delve into aspects of some of these in greater detail! (e.g. cell salvage -

You phone goes off - you roll over it is 2am - when you pick up it is a theatre nurse calling to ask if you can urgently come to the hospital immediately - the team are too busy to talk to you. The nurse tells you a woman has just arrived via ambulance from another small peripheral hospital. She had an emergency caesarean about 6 hours ago and hasn't stopped bleeding since. She has had 4 units of red cells and 4-5 litres of saline but nothing else. When you arrive 15min later surgery is underway but the surgical team tell you "everything we touch is bleeding" and you notice that she is even bleeding from the skin around her iv...... The anaesthetic registrar turns to you and says - "lets give her the fibrinogen concentrate -  we need to get on top of this coagulopathy right now!......" (*Fictitious case example) Hi Everyone, This week we are joined by a colleague and a great friend of mine Dr Hamish Mace, one of the co-authors of an article in the 2017 edition of Australasian Anaesthesia (aka the Blue Book

Merry Xmas! This weeks post was inspired by a recent unexpected case of severe hyperkalaemia in a severe pre-eclamptic - I have put together a fictitious case which is a little more severe in order to illustrate the principles of managing hyperkalaemia - I hope you enjoy & take it easy over Xmas! CASE HISTORY (*A fictitious patient history ) Your pager goes off - code blue medical labour ward! On arrival you are told the patient for whom the code was called has just arrived following an urgent transfer from another hospital. She presented to their service at 31 weeks with a headache, BP 190/100, proteinuria and mildly raised creatinine. She was diagnosed with severe pre-eclampsia, given labetalol, nifedipine and then transferred. She now appears confused with the following vital signs: HR 33/min, BP 74/55, SpO2 92%, RR 17/min (*Image courtesy www.lifeinthefastlane ) An immediate venous blood gas shows the following result: Na 139, K 8.4, pH 7.23, pCO2 37, pO2 63, Lactate 1.8 How are you going to ma

Hi everyone, This weeks post is the 5th in my mini series on patient blood management in obstetrics and gynaecology. We discuss some of the strategies we can use to avoid or treat excessive bleeding which can occur during gynaecological surgery or obstetric haemorrhage. After sitting down to put this section together I soon realised that there is actually a lot more to discuss than I anticipated - so I have decided to split this into two parts - surgical / physical and radiological techniques and then another one on anaesthetic / pharmacological and transfusion strategies. I am told by some trusted mentors that most podcast (or vodcast) listeners or viewers are time poor & have relatively shortish attention spans such that around 15min is the "sweet spot" for most of us. So based on that this talk is only meant to be a summary - I do hope to inspire you to go away and think about some of these techniques if they catch your interest. Do some more learning and research on your own. Some people have built who

You get called down to labour ward to place an urgent epidural in a labouring nulliparous woman. When you get there the team inform you that "she is going crazy with the pain", they can't get her to hold still, they are having trouble monitoring the fetus and they are really worried she might be having an abruption. They plead "can you please do an epidural so we can get control of the situation?". The partner then tells you that she wasn't planning on having an epidural because when she was younger she was told "she had mild spina bifida" He doesn't know any other details but as long as he has known her - over 10 years - she has never had it looked into and he doesn't think she has ever had surgery. You glance at her back and notice a small dimple and a tuft of hair in the lower lumbar region and she looks like she might have a slight scoliosis, oh dear..... This week I have managed to corner one of the rising stars in our department Gareth Ansell an anaesthetic provisional fellow in his final year of tra

Hi Guys, Number 4 in the patient blood management in obstetrics and gynaecology mini tute series. Intravenous iron - a relatively safe and effective treatment that can rapidly correct iron deficiency and anaemia, increasingly used in many of our patients. But how much do you really know on this topic? What are all these different preparations available? What are the risks / cautions / contraindications? What about anaphylaxis, skin staining and what the hell is the "Fishbane reaction!" Give us only 11min of your time and you will be surprised how much more knowledge you'll have on this topic! Time to hone your knowledge! If you want to be a real expert do the online package at www.bloodsafelearning.org And to maximise your learning we recommend you have a good understanding of iron physiology and the principles of PBM first ....so if you haven't already make sure you check out all the previous episodes: Patient blood management what is it? Iron physiology Oral iron   Screencast: https://yout

Hi Guys, Number 3 in the patient blood management in obstetrics and gynaecology mini tute series. Nice and short this time! Oral iron the treatment of choice for the vast majority of our patients - seems relatively simple yeah? Maybe but there's more than to it meets the eye! -  do it wrong and you'll fail miserably - if they take the wrong tablets, don't take them for long enough or if they were never going to take them in the first place! Time to hone your knowledge! If you want to be a real expert do the online package at www.bloodsafelearning.org Screencast (recommended): https://youtu.be/7LPCsng7tb8 Thanks for watching - comments and feedback please!    

Hi again! This is episode two in my mini tutorial series on patient blood management (PBM) in obstetrics and gynaecology. This one is on the basics of iron physiology - I can hear you all yawning already! However if you really want to know how to effectively treat anaemia with iron (oral, intravenous) and understand how to recognise and diagnose iron deficiency and iron deficiency anaemia (IDA) this is core knowledge....Give me 12-15min of your life and have a listen below - all of the mini tutorials which follow will make so much more sense you'll be thankful you made this small investment! Go to these sites they are great: 1 The National Blood Authority (NBA): https://www.blood.gov.au/patient-blood-management-pbm 2 Bloodsafelearning: https://bloodsafelearning.org.au/ Comments and feedback please! Thanks for listening and see you soon with the next one! Screencast version (recommended): https://youtu.be/6tfokBtpikc  

Gidday, Bonjour, Hi! This is the first episode in my mini series on patient blood management in O&G. Menorrhagia, haemorrhage, PV bleeding, iron deficiency, anaemia - any of this seem familiar? It should do! These issues affect a huge number of obstetric and gyaecologic patients, and as such this is an issue we should all be interested in learning more about - so I hope you find these interesting! I have been teaching around this topic to my colleagues and our registrars for a number of years now but thought maybe I should share some of this with you & a wider audience. The plan is to break this large topic up into smaller (aka palatable) sized mini topics of 10-15min. Let me know what you think! I am definitely not the authority in this area but I hope to inspire you to become interested and I thoroughly recommend you go to (in my humble opinion) the two following websites to get the real low down. These are definitely the go to authoritative resources for PBM in Australasia and a big thank you to the t

(*This is a fictional case) Your patient has just had a very difficult instrumental delivery in theatre after a prolonged obstructed labour. Unfortunately now her uterus won't contract despite oxytocin and ergometrine and she is bleeding pretty briskly. You clean her deltoid with an alco-chlorhex wipe, inject 250mcg (1 ampoule) of carboprost i.m. and cross your fingers that this will do the job. You lean over the drapes, talk to the obstetric team and start rubbing her uterus while they repair the episiotomy. Suddenly you hear a raspy wheezing sound from the head of the bed - you immediately jerk your head around and glance at your patients face - she looks terrified. Bronchospasm! She has pursed lips and is struggling to breathe, her sats probe says 75% and you suddenly wish you had signed up to do dermatology back in your intern year..... Your assistant runs around trying to find a nebuliser and salbutamol and over the next 4 minutes she becomes unresponsive, her breathing becomes progressively worse and

      Can the type of anaesthetic you get when you have your cancer surgery effect how long you live afterwards? Well the answer is.................. maybe. Listen to my 6min discussion here: https://www.obsgynaecritcare.org/wp-content/uploads/2017/09/Doestheanaestheticeffectcanceroutcomes.m4a I wouldn't be surprised that if you aren't an anaesthetist you may have never heard this topic discussed before. For those of us working in the anaesthesia field though this is a topic which has quietly been building momentum over the last decade or more and has really been getting a lot more press in the leading anaesthesia journals in the last couple of years. I was unable to attend the recent ANZCA ASM held in Brisbane but luckily they now provide us access to listen to recordings of many of the presentations online and one of the sessions on "onco-anaesthesia" caught my eye. I especially impressed with one speaker who discussed the following recently published paper. They analysed the outcomes of a large n

"You are called urgently into one of the birth suite rooms. A woman has just given birth, there is blood everywhere, she is moaning & breathing (barely). She is a ghastly pale / mottled colour and you can't feel a peripheral pulse..... it is a sunday afternoon, you work in a smaller hospital and the theatre team aren't on site......." Being faced with a shocked / peri-arrest obstetric patient who is literally exsanguinating in front of you is one of those nightmare situations that  those of us who work in obstetrics dread being faced with. The sudden uterine rupture, the unexpected placenta accreta, or an amniotic fluid embolism with ensuing severe coagulopathy all spring to mind. This is also not an uncommon event in theatre in women having surgery for placenta accreta/percreta or ruptured ectopics - where we are usually prepared for massive haemorrhage but despite this where we can suddenly find ourselves in a situation where the rate of blood loss is so catastrophic that we have lost control of the patien

  https://www.obsgynaecritcare.org/wp-content/uploads/2017/08/Oxytocin-in-labour-increases-PPH.m4a   The use of oxytocin to induce or augment labour is an established, commonly used practice that underpins a lot of modern obstetric practice. This technique is a undoubtedly a useful tool which has allowed us to improve maternal and fetal outcomes. For example to induce a timely delivery when maternal illness such as PET occurs or to avoid an operative delivery for a mother when their spontaneous progress in labour is slow. However, like most things in medicine (and life in general) there is no such thing as a "free lunch" and it is perhaps a less well recognised fact that the use of oxytocin in labour - especially at higher doses and for prolonged periods - is associated with an increased risk of postpartum haemorrhage due to uterine atony. Uterine atony is becoming more common in developed countries: The incidence of uterine atony causing postpartum haemorrhage in developed countries has increased markedl