International journal of obstetric anesthesia
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Int J Obstet Anesth · Feb 2019
ReviewObstetric anesthesia management of the patient with cardiac disease.
Cardiovascular disease is the leading cause of maternal mortality in much of the developed world. Risk stratification models can predict which patients are at greatest risk for maternal or fetal morbidity or mortality. ⋯ The obstetric anesthesiologist should formulate delivery plans for cardiac monitoring, labor analgesia, cesarean anesthesia, postpartum monitoring, as well as plans for obstetric or cardiac emergencies. Carefully co-ordinated multidisciplinary care of pregnant women with cardiac disease can result in successful outcomes.
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Int J Obstet Anesth · Feb 2019
ReviewMaternal critical care in resource-limited settings. Narrative review.
Maternal critical care reflects interdisciplinary care in any hospital area according to the severity of illness of the pregnant woman. The admission rate to intensive care units is below 1% (0.08-0.76%) of deliveries in high-income countries, and ranges from 0.13% to 4.6% in low- and middle-income countries. Mortality in these patients is high and varies from 0% to 4.9% of admissions in high-income countries, and from 2% to 43.6% in low- and middle-income countries. ⋯ Our aims were to (i) propose a more practical definition of maternal critical care, (ii) discuss maternal mortality in the setting of limited accessibility of critical care units, (iii) provide some accessible tools to improve identification of obstetric patients who may become critically ill, and (iv) confront challenges in providing maternal critical care in resource-limited settings. To improve maternal critical care, training programmes should embrace modern technological educational aids and incorporate new tools and technologies that assist prediction of critical illness in the pregnant patient. The goal must be improved outcomes following early interventions, early initiation of resuscitation, and early transfer to an appropriate level of care, whenever possible.
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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
Review Comparative StudyIs training in obstetric critical care adequate? An international comparison.
Obstetric critical care is an emerging discipline which cuts across speciality boundaries. We have analysed the training curricula in the three major specialities (obstetrics, anaesthesia and intensive care medicine) likely to be involved in the care of the critically-ill obstetric patient, to assess whether it is adequate to ensure effective training on this subject.