Hypothetical Case:

You are called to MFAU to see a woman who has just arrived via RFDS (royal flying doctor service)

She is a 23 y.o indigenous woman from the Kimberley in the far north of WA. She is 33/40 G1P0 complex social history and possible substance use disorders

She has PPROM (pre term premature rupture of membranes) and suspected early chorioamniotis and has been given antibiotics / nifedipine and a few litres of crystalloid fluid during the flight.

The obstetric team have evaluated her – she has small for gestational age baby, and is complaining of dyspnoea.

Her observations are: HR 110, NIBP 124/60, SpO2 91% on room air, T38.1

Her bloods are relatively normal except for an unexpected high BNP.

You do a focussed bedside transthoracic ECHO and unexpectedly see on the PLAX (parasternal long axis view) a classical hockey stick / domed appearance of severe mitral stenosis. She also has Pulmonary B-lines (indicating pulmonary oedema) and a flattened interventricular septum, very large atrium & doppler through the tricuspid valve confirms severe pulmonary hypertension. 

The team decides she would be better cared for in a hospital with cardiothoracic services – however she suddenly becomes more breathless – SpO2 86% on oxygen, NIBP 80/40 HR 125, and there is a prolonged foetal bradycardia…………………

Hi Everyone,

This week I am joined by Dr Clinton Ellis, a cardiothoracic anaesthetist based in Sir Charles Gairdner Hospital, and Graeme. We discuss the management of rheumatic heart disease in pregnancy – a challenging condition which unfortunately is still relatively prevalent amongst indigenous women here in Australia.

This was a wide ranging discussion so I have decided to split this into two 40min episodes. Even though we talk for over 80min I feel like we just scratched the surface on this! If you have any questions or comments send them through – I will try and get Clinton to answer them.

Finally a huge shout out and thank you to the Darwin based authors of the ANZCA 2023 Blue Book article on this condition: Namrata Jhummon-Mahadnac, Matthew Mathieson, and Akshay Hungenahally! See the link to their well written narrative review on this topic below:

Australasian Anaesthesia 2023 (aka the Blue Book) – see page 39 “Obstetric anaesthesia in rheumatic heart disease – a unique perspective from the Top End”

Oral vaccine could prevent rheumatic heart disease in NZ

VIDEO: Researchers close to a vaccine for strep-A and rheumatic heart disease

The post 149 Rheumatic heart disease in pregnancy part 2 appeared first on obsgynaecritcare.

Hypothetical Case:

You are called to MFAU to see a woman who has just arrived via RFDS (royal flying doctor service)

She is a 23 y.o indigenous woman from the Kimberley in the far north of WA. She is 33/40 G1P0 complex social history and possible substance use disorders

She has PPROM (pre term premature rupture of membranes) and suspected early chorioamniotis and has been given antibiotics / nifedipine and a few litres of crystalloid fluid during the flight.

The obstetric team have evaluated her – she has small for gestational age baby, and is complaining of dyspnoea.

Her observations are: HR 110, NIBP 124/60, SpO2 91% on room air, T38.1

Her bloods are relatively normal except for an unexpected high BNP.

You do a focussed bedside transthoracic ECHO and unexpectedly see on the PLAX (parasternal long axis view) a classical hockey stick / domed appearance of severe mitral stenosis. She also has Pulmonary B-lines (indicating pulmonary oedema) and a flattened interventricular septum, very large atrium & doppler through the tricuspid valve confirms severe pulmonary hypertension. 

The team decides she would be better cared for in a hospital with cardiothoracic services – however she suddenly becomes more breathless – SpO2 86% on oxygen, NIBP 80/40 HR 125, and there is a prolonged foetal bradycardia…………………

Hi Everyone,

This week I am joined by Dr Clinton Ellis, a cardiothoracic anaesthetist based in Sir Charles Gairdner Hospital, and Graeme. We discuss the management of rheumatic heart disease in pregnancy – a challenging condition which unfortunately is still relatively prevalent amongst indigenous women here in Australia.

This was a wide ranging discussion so I have decided to split this into two 40min episodes. Even though we talk for over 80min I feel like we just scratched the surface on this! If you have any questions or comments send them through – I will try and get Clinton to answer them.

Finally a huge shout out and thank you to the Darwin based authors of the ANZCA 2023 Blue Book article on this condition: Namrata Jhummon-Mahadnac, Matthew Mathieson, and Akshay Hungenahally! See the link to their well written narrative review on this topic below:

Australasian Anaesthesia 2023 (aka the Blue Book) – see page 39 “Obstetric anaesthesia in rheumatic heart disease – a unique perspective from the Top End”

Oral vaccine could prevent rheumatic heart disease in NZ

VIDEO: Researchers close to a vaccine for strep-A and rheumatic heart disease

The post 148 Rheumatic heart disease in pregnancy part 1 appeared first on obsgynaecritcare.

Hi everyone,

Pain during caesarean is a very challenging and distressing event – for the patient, their partner, the anaesthetist and all the staff present in theatre.

This week we catch up with Matt Rucklidge, who recently gave a presentation on this topic at the obstetric anaesthesia meeting in London. We discuss why this has become a “hot topic” in the anaesthesia world in recent times, what is the true incidence, and many other aspects of this difficult topic.

The following is a first person narrative story from a patient with commentary from an uninvolved obstetric anaesthetist. Disappointingly from elselvier this article is unfortunately not open access but is well worth a read:

Stanford SE, Bogod DG. Failure of communication: a patient’s story. Int J Obstet Anesth. 2016 Dec;28:70-75. doi: 10.1016/j.ijoa.2016.08.001. Epub 2016 Aug 23. PMID: 27717633.

Podcast: The Retrievals Season 2 from NY Times

Prevention and management of intraoperative pain during Caesarean sectionOrbach-Zinger, S. et al.BJA Education, Volume 25, Issue 2, 50 – 56

The post 147 Pain during caesarean a discussion with Matt appeared first on obsgynaecritcare.

Hi Everyone,

This week I sat down with Declan to discuss a fascinating therapy which is used in many areas of medicine.

This podcast has a bit of everything, a quiz, a part one viva, dubious animal experimentation, discussions about laxatives, and even some references to cosmology and the Big Bang.

Thanks Declan for another entertaining episode.

The post 143 Magnesium in medicine with Declan appeared first on obsgynaecritcare.

You are called to assess a pregnant woman who presents to your hospital complaining of shortness of breath. She is 36 weeks pregnant with twins and tells you she had been getting progressively short of breath over the last month but put it down to the physical effects of the twin pregnancy in her abdomen. However last night she couldn’t get her breath lying flat, had to sleep sitting up on 3-4 pillows and feels that “it is much worse”. On examination she has a respiratory rate of 24/min, SpO2 = 92%, HR 105/min, BP 95/45 and you can hear crepitations in both lung fields. Her initial blood tests come back showing a raised plasma BNP and a bedside ECHO is done by a helpful colleague – who says “subjectively her LV isn’t contracting very well”.

Hi everyone,

This week I sit down with Dr Faith Njue the most qualified person here in WA to discuss the rare but important disease – peripartum cardiomyopathy. (See Faith’s Bio below).

Join us in our wide ranging discussion which touches on the diagnostic challenges, demographics, proposed mechanisms and general principles involved in managing these complex patients.

Thanks Faith for a great discussion!

Dr Faith Njue – Bio

Faith Njue graduated from the University of Western Australia and completed cardiology training in Perth. She undertook further subspeciality training in advanced heart failure/ heart transplantation at Fiona Stanley Hospital and the University of Ottawa Heart Institute in Canada. Thereafter, she undertook further fellowship in cardio-obstetrics at the John Radcliffe hospital in Oxford (UK).

She has special interest in women’s cardiovascular health, heart disease in pregnancy and heart failure. Faith runs the dedicated Western Cardiology cardio-obstetrics clinic, designed to support women at risk of or with pre-existing heart conditions, through preconception counselling, pregnancy and into the post-partum period. Cardio-obstetrics is an expanding subspecialty that focuses on prevention, early detection, and appropriate management of cardiovascular disease in pregnancy.

She holds public consultant positions at Sir Charles Gairdner and Fiona Stanley hospitals. She is part of the Advanced heart Failure and Cardiac Transplant team at FSH. She is the cardiology clinical lead for High Risk pregnancy at FSH.

Anaesthesia and peripartum cardiomyopathy Chapman, K. Njue F, Rucklidge M. BJA Education, Volume 23, Issue 12, 464 – 472

Melanie Ricke-Hoch, Tobias J. Pfeffer, and Denise Hilfiker-Kleiner. Peripartumcardiomyopathy: basic mechanisms and hope for new therapies. Cardiovascular Research (2020) 116, 520–531. doi:10.1093/cvr/cvz252​

Bauersachs J, König T, van der Meer P, et al. Pathophysiology, diagnosis and management of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Study Group on peripartum cardiomyopathy. Eur J Heart Fail. 2019 Jul;21(7):827-843. doi: 10.1002/ejhf.1493. Epub 2019 Jun 27. PMID: 31243866​

2018 ESC Guidelines for the Management of Cardiovascular Disease During Pregnancy. European Heart Journal 2018. Vol 39;3165-3241​

Bromocriptine:

Koenig T, Bauersachs J, Hilfiker-Kleiner D. Bromocriptine for the Treatment of Peripartum Cardiomyopathy. Card Fail Rev. 2018 May;4(1):46-49. doi: 10.15420/cfr.2018:2:2. PMID: 29892477; PMCID: PMC5971672

Hilfiker-Kleiner D, Haghikia A, Berliner D, Vogel-Claussen J, Schwab J, Franke A, Schwarzkopf M, Ehlermann P, Pfister R, Michels G, Westenfeld R, Stangl V, Kindermann I, Kühl U, Angermann CE, Schlitt A, Fischer D, Podewski E, Böhm M, Sliwa K, Bauersachs J. Bromocriptine for the treatment of peripartum cardiomyopathy: a multicentre randomized study. Eur Heart J. 2017 Sep 14;38(35):2671-2679. doi: 10.1093/eurheartj/ehx355. PMID: 28934837; PMCID: PMC5837241.

The post 142 Peripartum cardiomyopathy with Dr Faith Njue appeared first on 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!

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

The post 141 Uterine inversion with Dr David Owen appeared first on obsgynaecritcare.

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:

Thanks Matt & David for sharing the experiences and knowledge learnt by the PAS team over the last 7 years.

https://www.kemh.health.wa.gov.au/~/media/HSPs/NMHS/Hospitals/WNHS/Documents/Clinical-guidelines/Obs-Gyn-Guidelines/Placenta-Accreta.pdf?thn=0

The post 140 The Placenta Accreta Spectrum Team at KEMH Part two. appeared first on obsgynaecritcare.

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:

King Edward Memorial Hospital website – The Placenta Accreta Spectrum guideline

The post 139 The Placenta Accreta Spectrum Team at KEMH Part one appeared first on obsgynaecritcare.

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!

International Journal of Obstetric Anesthesia

Effect of pneumatic leg compression on phenylephrine dose for hypotension prophylaxis via variable rate infusion at cesarean delivery: an unblinded randomized controlled trial

Transcutaneous electrical acupuncture point stimulation and quality of recovery following cesarean delivery: A randomized controlled trial

The post 138 Journal club with Graeme IJOA Nov 2024 appeared first on obsgynaecritcare.

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 out to the team from Rotunda Hospital in Dublin who wrote the recent narrative review published in IJOA on this topic!

The post 136 Total spinal anaesthesia with Graeme appeared first on obsgynaecritcare.