International journal of obstetric anesthesia
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Int J Obstet Anesth · Feb 2019
ReviewManagement of postpartum haemorrhage: from research into practice, a narrative review of the literature and the Cardiff experience.
Collins et al share their insights from 10 years of Cardiff research and pragmatic clinical experience managing postpartum hemorrhage.
Why is this important?
PPH incidence is increasing globally and is still the number one cause of maternal death. Many routine PPH transfusion practices are dogmatic and based upon non-pregnant trauma data. Applicability to PPH is at best questionable.
Of interest they note:
- The utility of fibrinogen measurement as an early indicator of coagulopathy and severe PPH, especially <2 g/L.
- The value of point-of-care testing, such as with ROTEM®.
- The typical maintenance of normal PT & APTT until 4-5 L of blood loss, unlike fibrinogen which was abnormal after ~2 L loss.
- The rarity of needing to replace factors other than fibrinogen even in severe PPH. FFP can usually be safely withheld in moderate-to-severe PPH when POCT is available.
- The value of fibrinogen concentrate over cryoprecipitate, although without value in pre-emptive formulaic treatment.
- The value and practicality of measuring blood loss versus estimation.
The take-away: Plasma fibrinogen is generally a more important target than PT or APTT in most PPH cases. (Placental abruption is an important exception.)
Interesting physiological tidbit... because normal term fibrinogen is 4 g/L and FFP fibrinogen is 2 g/L, undirected FFP transfusion in PPH could theoretically contribute to dilutional hypofibrinogenemia.
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Int J Obstet Anesth · Feb 2019
ReviewWhat's New in Obstetric Anesthesia: a focus on maternal morbidity and mortality.
The Ostheimer lecture is given each year at the annual meeting of the Society for Obstetric Anesthesia and Perinatology. It summarizes "What's New in Obstetric Anesthesia" based on a systematic evaluation of the relevant literature published in the previous calendar year. In this review I consider studies published in 2016 focused on the prevalence of, and risk factors for, maternal morbidity and mortality. I also discuss novel therapeutic approaches to the prevention and treatment of major sources of maternal morbidity and mortality.
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Int J Obstet Anesth · Feb 2019
Case ReportsSpinal anesthesia performed for cesarean delivery after external ventricular drain placement in a parturient with symptomatology from an intracranial mass.
We describe a case in which spinal anesthesia was undertaken in a pregnant patient with a space-occupying tumor and significant symptomatology. The collaborative efforts of all medical disciplines involved and the willingness of the neurosurgeon to discuss and help determine the safety of neuraxial anesthesia, culminated in placing an external ventricular drain to help monitor and manage intracranial pressure, so that we could proceed with spinal anesthesia and more easily monitor neurologic status.