International journal of obstetric anesthesia
-
Int J Obstet Anesth · Feb 2019
Meta Analysis Comparative StudyEphedrine versus phenylephrine as a vasopressor for spinal anaesthesia-induced hypotension in parturients undergoing high-risk caesarean section: meta-analysis, meta-regression and trial sequential analysis.
Phenylephrine is the preferred vasopressor for the prevention and treatment of spinal anaesthesia-induced hypotension during caesarean section, because studies on low-risk elective patients found it to have a less detrimental effect on umbilical artery pH compared with ephedrine. However, limited data exist from high-risk parturients and parturients with uteroplacental insufficiency. ⋯ Despite several studies and a large number of patients there was insufficient evidence to make a recommendation for choice of vasopressor in high-risk caesarean section. Trials with adequate power to detect differences in the incidence of fetal acidosis between ephedrine and phenylephrine are required to provide evidence-based guidance.
-
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.
summary -
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.