A nulliparous woman is admitted to labour ward in established labour, she is in a lot of pain and asks for an epidural. The team note that a full blood count taken 2 days ago showed a platelet count of 48. Is this a real thrombocytopenia? What are the causes of thrombocytopenia in pregnancy? How are they treated? What about epidural or spinal anesthesia? Will she bleed? What if it falls further and she needs platelets? Hi everyone, This week I have a new guest on the show Dr Simon Kavanagh a consultant haematologist and we do a two part deep dive into thrombocytopenia in pregnancy, what are the causes, what to do and who to call! (hint they specialise in diseases of the blood.....) Thanks Simon! References HOW Collaborative position paper on the management of thrombocytopenia in pregnancy - ANZJOG Jan 2021 This is published by Wiley and you may need to access it via your institution / library

Obsgynaecritcare

086 Thrombocytopenia in pregnancy with Dr Simon Kavanagh part 1

You are called to see a 31 yr old woman on the ward who is 8 hours postop after a diagnostic laparoscopy to investigate her longterm chronic pelvic pain. The nurse treating her is concerned because she is still complaining of pain despite many analgesics, however she is more concerned by the patient's increasingly erratic behaviour and agitation. Her heart rate is 108/min, NIBP 155/95, she appears sweaty, temp = 38.9C, appears restless and has some noticeable tremor. When you examine her she has very brisk reflexes and three beats of clonus in her ankles. Glancing at her med chart you see she is usually on desvenlafaxine 50mg/day, tramadol 100mg BD, and admits to using methamphetamine recreationally. Join Graeme and I as we discuss a rational approach to this sort of scenario, share some real life anecdotes and trade a few more dodgy dad jokes. Differential diagnoses (don't miss these)Deeper dive into SS syndrome, and NLMS References Tutorial of the Week 2010 Serotonergic Syndrome Serotonin Syndrome in the Perioperative Period BJA Education 2020

085 – Serotonergic and neuroleptic malignant syndromes with Graeme.

You are called to review a 35yr old woman at 36 weeks in labour ward who has had a couple of "funny turns" in the last 15 minutes where she became unresponsive and then seemed confused for a few minutes after. When you get there they tell you she is being induced with cervidil for premature rupture of membranes but she is not in active labour. Because of the PROM she has been started on erythromycin. She has also been unwell with hyperemesis most of the pregnancy but has been vomiting a lot over the last 2 days and has received a lot of medications to try and get on top of it including, ondansetron, droperidol, famotidine and maxalon - with only limited effect. She looks pretty thin and she says she has had a lot of trouble with her weight / nutrition because of her chronic nausea. The team have done some observations on her - she has a heart rate of 57/min, BP 100/55, she is afebrile and not tachypneic. At this stage the team thinks maybe she is fainting because she is a bit dehydrated but decide to send off some bloods and to do an ECG "to make sure there is nothing else going on". Her bloods come back and her potassium is only 2.2 and she is anaemic Hb 95. The ECG shows the following - what's wrong? (Image borrowed from LITFL - Hypokalaemia ECG changes • LITFL • ECG Library) Suddenly she passes out again whilst the ECG is attached, what are you going to do? Image borrowed from LITFL - Polymorphic VT and Torsades de Pointes (TdP) • LITFL Join Graeme and I as we discuss another fascinating topic after having a couple of patients recently with this challenging but fascinating syndrome.....

084 – Prolonged QT syndrome and Torsade de pointes with Graeme.

"Doctor did you know your next patient is a micro alert ?" What does this mean? Do we have to suit up as if there has been an outbreak of Ebola? Will Cefazolin 2g suffice? I just pushed in the vancomycin as recommended - why is the patient now on noradrenaline????? This week I am joined by Jodie Jamieson - an anaesthetic colleague and Claire Kendrick a pharmacist here at KEMH. We discuss the most commonly encountered microbiology alerts, especially MRSA and important safety points concerning some of the less commonly encountered antibiotics. Thanks Jodie and Claire! Note these are the microbiology alerts used in Western Australia - they will not be the same in other parts of the world! USEFUL LINKS Therapeutic Guidelines - https://www.tg.org.au KEMH Clinical Guidelines for health professionals - https://www.kemh.health.wa.gov.au/For-health-professionals/Clinical-guidelines/OG

083 – Micro alerts, MRSA, Vancomycin and antibiotics with Jodie & Claire

Hypothetical Case: A gynaecologist contacts you as the duty anesthetist to book an emergency laparoscopic oophorectomy. They tell you that the patient is a young woman who is currently intubated and ventilated on the intensive care unit after presenting 2 days earlier with a complex neurological syndrome, complicated by seizures requiring intubation. The surgeon tells you the ICU team have done some investigations, including an ultrasound demonstrating a complex ovarian mass, and CSF on a lumbar puncture positive for anti-NMDA receptor antibodies. What is Anti-NMDA receptor encephalitis? Why is it associated with gynaecology? When & how was it first discovered? Join Graeme and I as we discuss the ins/outs of this fascinating condition and share a few personal anecdotes of patient's we have encountered with this project. LINKS Pregnancy outcomes in anti-NMDA receptor encephalitis Acute psychiatric illness in a young woman: an unusual form of encephalitis MJA 2009 Josep Dalmau: exploring the paraneoplastic syndromes An update on anti-NMDA receptor encephalitis for neurologists and psychiatrists: mechanisms and models

082 – Anti-NMDA receptor encephalitis with Graeme

Hi everyone, A few weeks ago I sat down again with one of current trainees Sneha to discuss the interesting subject of the use smartphone applications in anaesthesia, and her latest offer to star in Survivor! LIST-OF-ANAESTHESIA-APPSDownload

081 – Apps in anaesthesia a discussion with Sneha

Hi Everyone, After over 2 months off Graeme and I back for our first podcast of 2021. In this episode we discuss some news and then dissect the recently published study which analysed the narrative descriptions of the 483 maternal deaths which occurred in the WOMAN study. The WOMAN trial was a large randomised study of 20000 women suffering postpartum haemorrhage comparing tranexamic acid and placebo published in 2017. There were 483 maternal deaths in this study and each death was accompanied with a short narrative description of the circumstances surrounding the death. This study discusses some of the common themes which are encountered frequently in these narratives. LINKS The WOMAN Study 2017 - Lancet website The WOMAN trial: clinical and contextual factors surrounding the deaths of 483 women following post-partum haemorrhage in developing countries

080 WOMAN trial narrative of 483 maternal deaths; discussion with Graeme.

Hi everyone, Graeme and I recorded this episode way back just before Christmas but because of technical issues here it is a little bit late! Disclaimer neither Graeme or I have any claim to being experts in exam technique but we hope that you find our opinions / advice of some use. Also my answers to these questions were easier for me than real life vivas because I knew in advance what the questions were going to be! Good luck to everyone sitting exams in 2021!

079 – Exam viva technique with Graeme

Hi Everyone, This week I am joined again by Mike and we discuss this fascinating syndrome of pregnancy, the management of which many of us have had drilled into us for many decades. Although this is a real syndrome which has been recognised for many years and has many serious potential consequences there are many controversies regarding it's physiology and treatment. In recent years advances in imaging technology and recent studies have questioned some of practices which were taught as if they were dogma...... How far can we tilt the operating table in theatre and does it really help? Compression of the aorta - really? Thanks Mike LINKS The Aortocaval Compression Conundrum - Analgesia and Anesthesia 2017 https://youtu.be/Y2T4MLiQTrM

078 – Aortocaval compression syndrome – exploring some dogmas with Prof Mike Paech

Hi Everyone, This week I am joined on the show with a new guest, consultant anaesthetist Dr Chris Mitchell. Chris is a colleague who also used to work with us at our women's hospital and is already famous for his range of USS regional anaesthesia needles (now manufactured by pajunk). Today we discuss the issue of the adverse environmental effects of our profession. In particular we focus on anaesthetic gases and what we can do to make a difference. LINKS British Journal of Anaesthesia 2020 - Environmental sustainability in anaesthesia and critical care

077 – Environmental effects of anaesthetics with Dr Chris Mitchell

Hi Everyone, Thanks to Mason Habel from Northern Health in Victoria, who contacted us a few months ago and suggested this topic to us. Join Graeme and I as we try to tackle this topic in a comprehensible manner. We do jump around a little bit, chasing anecdotes, interesting historical facts and the occasional dodgy dad joke but hopefully we get there in the end! LINKS 054 – Neurological injuries after childbirth and neuraxial anaesthesia. 053 – Complications after central neuraxial blocks in obstetric anaesthesia a discussion with Graeme 046 – Managing a patient with a postdural puncture headache PDPH with Dr Matt Rucklidge

076 – What I wish I knew about spinals & epidurals as an O&G resident.

A podcast discussing critical care, anaesthesia and pain medicine in obstetrics and gynaecology

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Obsgynaecritcare

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