Obsgynaecritcare

Hi everyone, This week I am joined again by Dr David Owen an obstetrician here at KEMH. We sit down to discuss uterine inversion - an acute obstetric emergency. Luckily this condition is relatively rare - however because of this there can be challenges in recognising and treating this condition even amongst experienced individuals. Should you be unlucky enough to encounter this rare condition, now having listened to our discussion you will be better prepared and confident you know what is required! Thanks again David for your research and preparation for this episode! References Uterine inversionPararajasingam, S.S. et al.BJA Education, Volume 24, Issue 4, 109 - 112 Unfortunately (as of Feb 2025) this article is not yet open access - but it is very good if you can get it through your hospital or college library.. Uterine Inversion for the layperson - Cleveland Clinic https://youtu.be/bYIPkNfPDUI

Hi Everyone, Welcome to Part Two of our discussion with two of the founding members of the Placenta Accreta Spectrum Team here at KEMH Dr Matt Epee-Bekima and Dr David Owen. This team was conceived in 2017 and began operating in 2018 - and has now cared for over 75 women with PAS - including 24 alone this year (2024). In this episode we continue our initial discussion with a more detailed dive into: Surgical management - team members, techniques and approach Techniques for catastophic bleeding - manual aortic compression, vascular clamping, interventional radiology Postpartum issues Controversies (ICU vs HDU, leaving placenta in -situ) Thoughts for the future Thanks Matt & David for sharing the experiences and knowledge learnt by the PAS team over the last 7 years. References https://www.kemh.health.wa.gov.au/~/media/HSPs/NMHS/Hospitals/WNHS/Documents/Clinical-guidelines/Obs-Gyn-Guidelines/Placenta-Accreta.pdf?thn=0

Hi Everyone, This week I had the privilege of sitting down and recording two fascinating episodes with two of the founding members of the Placenta Accreta Spectrum Team from here at KEMH, Dr Matt Epee-Bekima and Dr David Owen. In this first episode we discuss the following: Definitions and pathology of placenta accreta spectrum What is the story behind the formation of the PAS team? Screening / Identification / Diagnosis and referral The optimisation and planning of the patient's journey. References King Edward Memorial Hospital website - The Placenta Accreta Spectrum guideline

Hi Everyone, Join Graeme and I as we discuss two articles chosen from last months edition of IJOA (International Journal of Obstetric Anesthesia). In the first we discuss an article exploring whether the use of intermittent calf compression can reduce hypotension and vasopressor use in women undergoing caesarean section under spinal anaesthesia. The second article looks at the utility of preoperative electrical stimulation of acupressure points prior to caesarean section reduces postoperative pain and improves the quality of maternal recovery. There's a sprinkling of our usual dad jokes at the end. For regular listeners to the show join us again later this month when we hopefully will have a couple of episodes dedicated to the management of placenta accreta spectrum and an interview with the founders of the placenta accreta service setup 7 years ago here at KEMH - see you then! References International Journal of Obstetric Anesthesia Effect of pneumatic leg compression on phenylephrine dose fo

The next patient on your elective list arrives in theatre. She is a 35 year old woman booked for hysteroscopy to investigate her menorrhagia. She has no co-morbidities so wasn't seen preoperatively in a clinic. She tells you that she has no medical problems but did start on Wegovy for weight loss about 4months ago and has now lost about 12kg. She hasn't eaten anything since 9pm last night - it is now 10am. You were planning a general anaesthetic and a supra-glottic device, but now you're not sure what you should do? Hi everyone, This week I am joined by Erin and we discuss in detail the perplexing topic of GLP1 receptor agonists. These new wonder weight loss drugs seem to be all the rage and certainly things look rosy if you have shares in Novo Nordisk (the manufacturer). However they are not so great if you provide anaesthesia.... We discuss their relationship with delayed gastric emptying and the risk of aspiration. References ANZCA GLP1 clinical practice recommendation June 2024 ASA consen

Your patient arrives in the anaesthetic room next to theatre, she's booked for a non elective caesarean for failure to progress. She has an epidural in situ and you decide try to top it up - however after 25ml of lignocaine 2% with adrenaline and around 20min of waiting the block is stuck at the umbilicus and she can still move her legs relatively freely. This is obviously not going to be adequate - she is adamant she wants to be awake to see her baby born. You sit her up, pull out the epidural and do a single shot spinal with 2.1ml of heavy bupivacaine 0.5% + fentanyl 15mcg - after all you don't want this block to fail as well! You clean her back, lie her down and turn to talk to the midwife. When you turn back to the patient 30s later she looks a little purple and isn't breathing....... Hi everyone join Graeme and I this week as we discuss total spinal anaesthesia - a fascinating but somewhat scary rare emergency which can occur when we use regional anaesthesia in obstetric practice. A big shout ou

What is the EXIT procedure? Who is it used for and how do we do it? In our institution this procedure only occurs on average every 3-4 years. It is an event where a large diverse group of individuals, who often have never met each other, come together for a brief period of time to work as a highly complex team to achieve a great result for both the mother and baby. Join Lloyd and I as we do a deep discussion on this uncommon but challenging multi-disciplinary procedure. References Maternal anesthesia for EXIT procedure: A systematic review of literature. The management of congenital upper airway anomalies and the ex-utero intrapartum treatment (EXIT) procedure

Hi Everyone, This week Matt and I agreed to get together to do another journal club episode (or more accurately I printed out an article, put it in Matt's pigeon hole and told him to make himself available or else!). We went to one of our favourite journals IJOA (International Journal of Obstetric Anesthesia), where we chose an article from the latest edition published in May. The article is entitled "A narrative review of the literature relevant to obstetric anesthesiologists: the 2023 Gerard Ostheimer lecture." The background to this article is that every year the north american Society of Obstetric Anesthesia and Perinatology (SOAP) hold an annual conference. One of the highlights of these annual conferences is this lecture which is researched and then presented by a well respected obstetric anesthesiologist from the north american community. The lecture is a narrative review of the previous years published literature highlighting important papers and discussing their importance and relevance

Hi everyone, This week I sit down with Jacob one of the provisional fellows in our department and we discuss the findings from the latest UK National Audit Project - NAP7 - which this time investigated Perioperative cardiac arrest. REFERENCES NAP7 - Royal College of Anaesthetists

A woman collapses with abdominal pain in a restaurant & then the initial evaluation in the ED she is diagnosed with suspected ruptured ectopic pregnancy. She is brought straight into your theatre and you perform a rapid sequence induction. You place your video laryngoscope into her mouth and all you see is vomitus and fluid, your yankauer sucker is blocked with food and doing nothing............ Hi everyone, This week I am joined by Dr Nathan Blakely one of our enthusiastic trainees to discuss an area he has taken a personal interest in ---- the management of the soiled airway. Thanks Nathan! Blood in Airway: Useful Links / References https://youtu.be/Jaq-vHbcGi0 https://youtu.be/oMXkGgoRMpE Cook T, Woodall N, Frerk C, Project FNA. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. British journal of anaesthesia. 2011;10

As the DA you are paged to come to PACU to review a patient with pre-eclampsia who has just had a PPH and a repair of a perineal tear after delivering in labour ward. The O&G team ordered a VBG because she was febrile and they want to assess her lactate and start her on some antibiotics. The O&G registrar is concerned however because her potassium / K has come back as 7.8 mmol/L.... Join Natalie and I as we discuss the issue of hyperkalaemia specifically in the context of women suffering from pre-eclampsia. Why are they at risk of this important electrolyte abnormality and what are the principles of management? We also review a recent paper addressing some of the myths surrounding the treatment of acute hyperkalaemia (thanks to Casey at Broomedocs.com for bringing this paper to our attention). Useful References Gupta AA, Self M, Mueller M, Wardi G, Tainter C. Dispelling myths and misconceptions about the treatment of acute hyperkalemia. Am J Emerg Med. 2022 Feb;52:85-91. doi: 10.1016/j.ajem.2021.1

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

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

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 Owe

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

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 P

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.

Hi everyone, Join us this episode - Declan and I have scoured the literature for a few interesting articles of varying degrees of quality! We had fun discussing these articles and hopefully you will also enjoy our discussion. Hopefully we will make this a regular feature every 3-4 months! Articles Discussed 1 - Effect of Dural-Puncture Epidural vs Standard Epidural for Epidural Extension on Onset Time of Surgical Anesthesia in Elective Cesarean DeliveryA Randomized Clinical Trial In this RCT published in JAMA - the time to surgical anaesthesia was 4 min faster when topping up a dural puncture epidural in comparison to a standard epidural catheter. 2 - Neuraxial buprenorphine for post-cesarean delivery analgesia: a case series This correspondence from the International Journal of Obstetric Anesthesia (IJOA) this year discussed the experience of a small hospital which decided to use neuraxial buprenorphine when there was a morphine shortage. 3 - There's No Such Thing as “Nonjudgmental” D

You are called to labour ward to place an epidural in a nulliparous woman who is obviously extremely distressed in pain. After you sit her up to clean her back you notice she has a long scar running down the middle of her back. Between contractions she tells you she had surgery as a teenager to straighten her back.....what does this mean? Hi Everyone, Graeme regularly teaches this topic to our anaesthesia trainees and I was surprised to realise that we haven't done a podcast on this already. Join us as we discuss scoliosis, spina bifida, spinal surgery and other assorted spinal issues. TRAGIC CASE OF AIRWAY DEATH DUE TO SEVERE KYPHOSCOLIOSIS - FROM WEST AUSTRALIAN

Hi Everyone, Whole blood, freeze dried plasma, refrigerated or frozen platelets.... On Oct 31st - Nov 3 Graeme, Emelyn and I attended the THOR - THUNDER conference hosted here in Perth at the Rendezvous Hotel in Scarborough. Who is THOR? In their own words: The THOR (trauma haemostasis oxygenation resuscitation) organization is a resuscitation and blood network, originating in Norway a decade ago, and now boasting global reach. It has built an avid following of both civilian and military resuscitation clinicians and scientists, covering both pre-hospital and hospital management of critically unwell patients. The THOR vision is to improve outcomes from traumatic haemorrhagic shock by optimising the acute phase of resuscitation. The mission is to develop and implement the best practices for haemorrhagic shock resuscitation from pre-hospital care right through to the completion of the acute phase of hospital resuscitation. Thor group website: Trauma Hemostasis and Oxygenation Research Network