Episode 162: Hypertensive Disorders of Pregnancy with Juanita Henao

In this 162nd episode I welcome Dr. Henao back to the show to discuss hypertensive disorders of pregnancy and how to manage them.

CLARIFICATIONS:

  1. During our discussion of treatment of eclamptic seizures Dr. Henao said benzos were first line treatment. This is assuming the patient is already getting magnesium. For test questions, the answer for first line treatment should be Mg. In reality, patients will likely get both at the same time.
  2. Serum Mg concentrations can be reported as mmol/L, meq/L or mg/dL. The important ranges to know for testing (though in reality different people may get symptoms at different times) are a therapeutic range of 2-3.5 mmol/L or 4-7 mEq/L or 5-9 mg/dL; A loss of patellar reflexes at >3.5, >7, >9; Respiratory paralysis at >5, >10, >12 and cardiac arrest at >12.5, >25, >30. EKG changes including prolonged PR and widened QRS happen in much the same range as loss of patellar reflexes, maybe a bit before but there is a lot of overlap.

References:

  1. Hofmeyr R, Matjila M, Dyer R. Preeclampsia in 2017: Obstetric and Anaesthesia Management. Best Pract Res Clin Anaesthesiol. 2017 Mar;31(1):125-138.
  2. Dhariwal NK, Lynde GC. Update in the Management of Patients with Preeclampsia. Anesthesiol Clin. 2017 Mar;35(1):95-106.
  3. Aya AG, Mangin R, Vialles N, Ferrer JM, Robert C, Ripart J, de La Coussaye JE. Patients with severe preeclampsia experience less hypotension during spinal anesthesia for elective cesarean delivery than healthy parturients: a prospective cohort comparison. Anesth Analg. 2003 Sep;97(3):867-72.
  4. Roberge S, Nicolaides K, Demers S, Hyett J, Chaillet N, Bujold E. The role of aspirin dose on the prevention of preeclampsia and fetal growth restriction: systematic review and meta-analysis. Am J Obstet Gynecol. 2017 Feb;216(2):110-120.
  5. David Chestnut Cynthia Wong Lawrence Tsen Warwick D Ngan Kee Yaakov BeilinJill Mhyre Brian T. Bateman Naveen Nathan. Chestnut’s Obstetric Anesthesia: Principles and Practice. 5th edition. Chapter 36: Hypertensive Disorders. Pg 825-859

Killers of the Flower Moon (Dr. Henao’s random recommendation): https://www.amazon.com/Killers-Flower-Moon-Osage-Murders/dp/0385534248

Episode 161: Dual Training in Anesthesiology and Emergency Medicine

In this 161st episode I welcome Drs. Regan and Lester to the show to discuss the country’s first combined Anesthesiology and Emergency Medicine dual training program.

Website for the program: https://www.hopkinsmedicine.org/emergencymedicine/combined-residency/

Episode 160: Non-OB Surgery in Pregnancy With Dave Berman

In this 160th episode I welcome Dr. Dave Berman back to the show to discuss anesthesia for non-OB surgery during pregnancy.

References:

1. Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology. Anesthesiology 2016;124(2):270–300.

2. Nonobstetric Surgery During Pregnancy – ACOG [Internet]. [cited 2019 Jul 18];Available from: https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Nonobstetric-Surgery-During-Pregnancy?IsMobileSet=false

3. Tolcher MC, Fisher WE, Clark SL. Nonobstetric Surgery During Pregnancy. ObstetGynecol 2018;132(2):395–403.

4. UpToDate [Internet]. [cited 2019 Jul 18];Available from: https://www.uptodate.com/contents/management-of-the-pregnant-patientundergoing-nonobstetric-surgery

5. Upadya M, Saneesh PJ. Anaesthesia for non-obstetric surgery during pregnancy. Indian J Anaesth 2016;60(4):234–41.

6. Reitman E, Flood P. Anaesthetic considerations for non-obstetric surgery duringpregnancy. Br J Anaesth 2011;107 Suppl 1:i72–8.

7. Nejdlova M, Johnson T. Anaesthesia for non-obstetric procedures during pregnancy. Contin Educ Anaesth Crit Care Pain 2012;12(4):203–6.

8. Mazze RI, Källén B. Reproductive outcome after anesthesia and operation during pregnancy: a registry study of 5405 cases. Am J Obstet Gynecol 1989;161(5):1178–85.

9. Committee on Obstetric Practice and the American Society of Anesthesiologists. Committee Opinion No. 696: Nonobstetric Surgery During Pregnancy. Obstet Gynecol 2017;129(4):777–8.

10. Wilcox AJ, Weinberg CR, O’Connor JF, et al. Incidence of early loss of pregnancy. N Engl J Med 1988;319(4):189–94.

11. Davidson AJ, Disma N, de Graaff JC, et al. Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial. Lancet 2016;387(10015):239–50.

12. Sun LS, Li G, Miller TLK, et al. Association Between a Single General Anesthesia Exposure Before Age 36 Months and Neurocognitive Outcomes in Later Childhood. JAMA 2016;315(21):2312–20.

13. Center for Drug Evaluation, Research. FDA Drug Safety Communication [Internet]. U.S. Food and Drug Administration. 2019 [cited 2019 Jul 21];Available from: http://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communicationfda-review-results-new-warnings-about-using-general-anesthetics-and

14. Huang S-Y, Lo P-H, Liu W-M, et al. Outcomes After Nonobstetric Surgery in Pregnant Patients: A Nationwide Study. Mayo Clin Proc 2016;91(9):1166–72.

Episode 159: Postpartum hemorrhage with Juanita Henao

In this 159th episode I welcome Dr. Juanita Henao to the show to discuss prevention and management of postpartum hemorrhage.

One CORRECTION: At about minute 4:30 Dr. Henao states that in women with PPH the mortality rate is 10% but what she meant to say is that PPH accounts for 10% of maternal deaths in the United States.

References:

Thorneloe, J.C.A. Carvalho, K. Downey,M. Balki. Uterotonic drug usage in Canada: a snapshot of the practice in obstetric units of university-affiliated hospitals. Int J Obstet Anesth. 2019 Feb;37:45-51.

Hian Yan Voon , Haris Njoo Suharjono , Asrul Akmal Shafie , Mohamad Adam Bujang Carbetocin versus oxytocin for the prevention of postpartum hemorrhage: A meta-analysis of randomized controlled trials in cesarean deliveries. Taiwan J Obstet Gynecol. 2018 Jun;57(3):332-339.

WOMAN trial collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017 May 27;389(10084):2105-2116.

Main EKGoffman DScavone BMLow LKBingham DFontaine PLGorlin JBLagrew DCLevy BSNational Partnership for Maternal SafetyCouncil on Patient Safety in Women’s Health Care.National Partnership for Maternal Safety: Consensus Bundle on Obstetric Hemorrhage. Obstet Gynecol. 2015 Jul;126(1):155-62.

Duffield A1McKenzie CCarvalho BRamachandran BYin VEl-Sayed YYRiley ETButwick AJ. Effect of a High-Rate Versus a Low-Rate Oxytocin Infusion for Maintaining Uterine Contractility During Elective Cesarean Delivery: A Prospective Randomized Clinical Trial. Anesth Analg. 2017 Mar;124(3):857-862

David H. Chestnut, Cynthia A Wong, Lawrence C Tsen, Warwick D Ngan Kee, Yaakov Beilin, Jill Mhyre. Chestnut’s Obstetric Anesthesia: Principles and Practice. Fifth edition. Chapter 38, Anterpartum and Postpartum, Hemorrhage.